Beruflich Dokumente
Kultur Dokumente
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
Part TwoTreatment
9 Philosophies and Principies of Binocular Vision
Therapy I 263
Philosophies | 263
Principies | 268
Pa rt Th reeTec h n q u es
17 Vision Training for Eso Deviations I 489
MirrorStereoscope(T13.2,T14.4) | 490
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
Foreword
By popular demand, and need, comes this new, ing normal binocular visin, such as stereopsis and
updated, and expanded fourth edition of Drs. Grif- an ncreased field-of-view. Furthermore, an entire
fin and Grisham's now classic Binocular Anomalies: section is now devoted to the objective recording
Diagnosis and Vision Therapy. In the intervenng and evaluation of reading eye movements using the
period since publication of the previous edition Visagraph system. This seems most appropriate as the
(1995), the important and challenging rea of reading demands imposed by society continu to
abnormal binocular visin has continued to flour- ncrease, in both adults and children. Finally, the
ish, and even expand, n optometry, with spill-over addition of a self-assessment test should serve to test
into other disciplines. For example, visin therapy is one's newly acquired knowledge with practica! clini-
beginning to be ntroduced into selected grade cal examples, including full answers, for immediate
school systems using a team approach, including feedback and reinforcement.
consultant optometrist, teacher, therapist, and par- In addition to these new components, the tradi-
ent, with formal legislative support. Furthermore, tional reas of optometric visin therapy are pre-
visin therapy's unique contribution to patients with sented n detall with abundant graphics and case
acquired brain injury n which vergence, accommo- examples, both with respect to diagnosis and thera-
dative, reading, and visual-spatial dysfunctions peutic aspects. To the best of my knowledge, this s
abound has only recently been appreciated by the most complete and encyclopedic treatise on
many, including the traditional medically based visin therapy ever produced, incorporating an
rehabilitation team consisting primarily of physia- appropriate blending of clinical knowledge and
trists and occupational therapists. training protocol with substantial theoretical bases
The updated and new topics included in this latest to satisfy one's ntellectual cravings.
edition are consistent with these deas. For example, Henee, once again, Drs. Griffin and Grisham
the presence of ocular disease may have pronounced share selflessiy their years of clinical experience and
adverse effects on the binocular state (e.g., central devotion to optometric visin therapy. The result is
scotomas n macular degeneration and peripheral an outstanding book that should guide students and
scotomas in retinitis pigmentosa). These will reduce practitioners alike in their quest for a greater under-
disparity drive to the vergence system, resulting n standing of binocular anomalies and their more
fusional problems and, furthermore, produce reading effective and efficacious treatment.
mpairment due to scanning limitations. In addition,
recent research advances n basic aspects of binocu- Kenneth J. Ciuffreda, O.D., Ph.D.
lar visin clearly demnstrate the subtle but impor- DistinguishedTeaching Professor and Chairman
tant adverse effects on dynamic motor control (e.g., Department of Vision Sciences
grasping rapidly for a small or moving object) when State College of Optometry
binocular function is compromised. This s n addi- State University of New York
tion to the more traditional y cited advantages of hav- New York
XIII
Preface
This fourth edition of Binocular Anomalies: Diagno- addition s by popular request of students and prac-
sis andVision Therapy follows the format and philos- titioners. All questions follow the exact chapter-by-
ophy of the third edition. When the exact diagnosis chapter sequence of topics presented n the text.
of a binocular anomaly is known, exact visin ther- Particularly updated topics include diseases
apy can be prescribed. Part One covers diagnosis, affecting binocular visin, binocular anomalies
and Part Two is on treatment We have updated and reading dysfunction, advantages of good bin-
many of the topics, because there have been impor- ocular visin, and pharmacologic treatment. Addi-
tant advances in diagnostic procedures and training tional case examples are included to Ilstrate the
techniques. Deleting some of the od material has mplementation of visin therapy and to help the
been necessary to allow room for discussion of new clinician connect theoretical principies with spe-
methods for diagnosis and treatment. cific visin therapies.
We take the accepted view that visin therapy A CD-ROM is included n which popular train-
encompasses all modes of treatment of binocular ing techniques are discussed; these techniques can
visin problems. Besides visin training, we be downloaded and modified according to the
include the use of lenses and prisms, occlusion, wishes of each practitioner.
pharmaceutical treatment, motivational methods, We have attempted to be semantically consis-
and extraocular muscle surgery when necessary. tent with terminology so that the reader can sean
Vision therapy of binocular anomalies is for treat- through various chapters without ambiguity and
ment of strabismus, heterophoria, amblyopia, and always know what specified terms mean. For
dysfunctions affecting educational, vocational, and example, we speak of viewing at far (e.g., 20 ft or
avocational performance. As n the previous edi- 6 m) rather than using distance, which many clini-
tion, each visin training technique (active visin cians use in their customary discourse. (One
therapy) s identified by a "T" number for easy could wonder if distance is referring to far dis-
identificaron and referencing. Diagnostic methods tance, intermedate distance, or near distance.) In
are referred to as procedures so that confusin can addition, we have set eso and exo (and the like)
be avoided between methods of testing (proce- apart as single words when combined with fixa-
dures) and training (techniques). Although these tion disparity and deviation. We have also
techniques are discussed thoroughly in general ncluded older terms n parentheses when a term
terms, we thought t would be helpful to include s ntroduced. For nstance, visuoscopy was once
specific, detailed discussions n a "how-to" format, spelled as visuscopy; we provide the reader with
similar to the teaching method of a preclinical lab- both terms initially and retain the more accepted
oratory for students and practitioners (especially term throughout the book. Our ntention s to
primary-care clinicians) and other professionals enhance the readability of the text.
and therapists wishing to review and learn new We thank the following individuis for their help
techniques. Part Three presents such detailed in making this new edition possible: Karen Ober-
instructions, including illustrations, on the most heim, Judy Higgins, Judy Badstuebner, Ronda Bar-
frequently used vision-training techniques. These ton, L. Ernie Carrillo, Dr. James Saladin, Dr. James
instructions are applicable to clinicians as well as Bailey, Dr. Walter Chase, Kirsten Griffin, R.N., Dr.
to parents and patients for home training. Also William Ridder, Dr. Lawrence Stark, Kim Vu, David
ncluded n Part Three are recommended sequenc- West, Donnajean Matthews, Denise Hess, Doreen
ng of techniques for specific binocular anomalies Keough, Pam Bickel, Lois Keup, and Holly Hoe.
and practice management principies.
A self-assessment test of 100 multiple-choice John R. J. David Grisham Berkeley
questions and explanatory answers s ncluded. This Griffin
Fullerton
xv
chapter 1 / Normal Binocular Vision
Binocular visin pertains to the motor coordina- motor system is to direct the alignment of both
tion of the eyes and the sensory unification of their foveas (foveae) to the object of attention with i n
respective views of the world. This is a unitary pro- the visual field and to maintain them n that
cess but, for the sake of analysis, t can be broken position as long as the individual requires. The
into sensory and motor components. motor system holds the eyes in alignment and
The sensory side starts with light emitted or sustains clear focus, thereby ensuring the main-
reflected from physical objects n the externa! tenance of binocular visin. Frequently, how-
environment that is brought into focus on the ret- ever, the complete remediation of binocular
ina by each eye's optics. This pattern of light visin anomalies requires attention to both sen-
energy s transformed by retinal photoreceptors sory and motor aspects.
into neuroelectrical impulses and is transmitted to
the visual perceptual reas of the cerebral cortex
and certain subcortical reas. The result of com-
VALU OF NORMAL
plex neural processing, which is only partially
BINOCULAR VISION
understood, is the sensation of object attributes
(i.e., form, color, intensity, and position in space) One distinctive perceptual attribute of humans,
that, n turn, culminates n an immediate, vivid among all primates, s a high degree of stereo-
perception of object identity and of the relations scopic binocular visin. Our skills in hunting,
of objects in the external environment. food gathering, and tool making have helped to
The motor positioning and alignment of the direct our evolution. In the competition for food,
eyes completely subserve the primary sensory shelter, and safety, stereopsis is one of several
function of image unification and allow visual attributes that evidently provided mportant
perception to proceed efficiently. The task of the 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 sin ster [left
eye].) '
ern age, stereoscopic visin contines to provide difference is even greater when uncorrected
individuis with important information about ametropia is present in each eye.
their environment. Stereopsis significantly aids in Binocular visin, in contrast to monocular
making judgments of depth, whether at school, visin, minimizes the effects of ocular disease.
the workplace, or the sports field. It also helps to Binocular summation of ocular images signifi-
stabilize sensory and motor fusin and can be cantly heightens contrast sensitivity, by approxi-
considered a "barometer" of the status of binocu- mately 40%. 3 In practical terms, this is helpful
lar visin. for driving at night and working under low-illu-
Besides stereopsis, there are other benefits that mination conditions. Individuis with certain
derive from normal binocular visin. The most ocular diseases (e.g., optic nerve demyelination
obvious benefit of having two eyes is that, n case in mltiple sclerosis) may demnstrate profound
of injury to one, there is an eye in reserve. This differences in contrast sensitivity between binoc-
might be called the "spare tire" concept. Whereas ular and monocular sight.
the loss of sight in one eye can cause some signifi- There are several vocational and avocational per-
cant problems for an individual, the loss of sight in formance benefits of having good binocularity.
both eyes can be devastating. Sheedy et al.4 described superior task performance
The binocular individual also has the advantage under binocular versus monocular viewing condi-
of a large field of visin (Figure 1-1). The binocular tions (Table 1-1). Differences favoring binocular
field of visin usually is at least 30 degrees larger viewing were notable n such tasks as card filing,
than the monocular field. needle threading and, surprisingly speed of word
Binocular visual acuity normally is better by decoding. No significant difference was noted,
approximately one-half line of letters on a Snellen however, in letter counting on a video display termi-
chart, as compared with either eye alone. 1'2 The nal or in throwing beanbags accurately. Trese inves-
Chapter1 5
TABLE1-1. Superority of Task Performance under Binocular Conditons as Compared with Monocular Conditions
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).
Levator Superior SR
Palpebrae^ obligue
Superior
Rectus
A LR = :
?
Oculomotor
Foramen
Inferior
Rectus
Pulley IR
Inferior -12mm
Oblique
- 24mm
fore, becomes the effective mechan cal origin for of rectus pulleys has been implicated as a cause of
the action of the superior oblique (Figure 1-4). noncomitant strabismus.
The inferior oblique is the only extraocular mus-
cle that does not orignate n the orbital apex; t
arises from a small fossa in the anterior, inferior, Accommodation
orbital wall (the maxilla bone). This muscle's Accommodation s one member of the oculomo-
course parallels the reflective portion of the tor triad that also includes pupillary constriction
superior oblique muscle, again forming a 51- and accommodative convergence, all mediated
degree angle as it courses inferiorly and laterally by the third nerve nucleus n the midbrain.
across the globe and over the inferior rectus to Accommodation is a reflex initiated by retinal
insert in the inferior, posterior quadrant. blur; t can, however, be consciously controlled.
Evidence from magnetic resonance imaging stud- The afferent pathway extends from the retina to
ies of the orbit indcate that all rectus muscles pass the visual cortex and projects from rea 19 to the
through pulleys, structures composed of connective pretectum and superior colliculus before enter-
tissue and smooth muscle, that are coupled to the ing the Edinger-Westphal nucleus of the third
orbital wall and located just behind the equator of nerve complex. Projections from the frontal eye
the globe.6"8 In effect, these pulleys ("sleeves") fields (traditionally referred to as Brodmann's
rather than the attachments of these muscles at the rea 8) also enter the third nerve complex that, in
annulus of Zinn in the back of the orbitact as the part, mediates conscious control of accommoda-
origin for the action of the rectus muscles. In most tion. The efferent component of the reflex are
people, the location of these pulleys s remarkably from the third nerve complex synapses n the cil-
consistent and does not shift much with rotation of iary ganglion and again n the ciliary muscle
the globe into the various fields of gaze. Many stra- which, in turn, effectuates the change of lens
bismic individuis have been found to have normal power (Figure 1-5).
pulleys, although some do not. Abnormal location
they are neurologically distinct, with different cen- Vestbulo-Ocular Eye Movements
tral pathways and dynamic properties. The vestbulo-ocular system stabilizes the eyes on
a target during head movements and can be tested
Saccades with the "doll's-head" maneuver. The dynamics of
Saccadic eye movements refer to ballistic-type eye vestibular eye movements are relatively fast, hav-
movements that carry the eye quickly from one ing a latency of only 16 milliseconds as compared
target in space to another (i.e., a change in fixa- with the 75-millisecond latency of the pursuit sys-
tion). There are several types of saccades: (1)the tem.11 As the head turns, vestbulo-ocular reflexes
fast phases of either vestibular or optokinetic nys- are initated by the movement of fluid wthin the
tagmus; (2) spontaneous saccades occurring semicircular cais of the inner ear. For example,
approximately 20 times per minute and used to stimulation of the left vestibular nucleus causes
sean the environment; (3) reflexive (nonvolitional) impulses to travel to the right pontine gaze center.
saccades that occur in response to any new envi- From there, the pathway to the extraocular muscles
ronmental stimulus; and (4) intentional saccades is the same as that described for saccadic eye
A F F E R E N T
Retinal image blur LGN reas 17-19
Lens of eye -< ----------- Ciliaty muscle Ciliary ganglion 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].;
8 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.)
movements. Stimuiation from the left vestibular cally.iz The assumption is that the right and left
nucleus by a left head turn causes compensatory occipital reas are connected to each right and
dextroversion. left pontine gaze center, so that stimulation from
one occipital lobe may stimulate both the left and
Pursuits right pontine gaze centers for left or right pursuit
The pursuit system mediales constant tracking of movements. Because of this double coverage,
a moving target and is the slowest of the three pursuits may sometimes be intact despite an
eye movement systems. Pursuit eye movements extensive lesin in one hemisphere of the brain
are mediated via the occipitomesencephalic that could also cause a homonymous hemianopic
pathway. Impulses travel from the occipital lobes visual field loss (Figure 1-8).
(presumably from Brodmann's rea 19) to the
midbrain and pontine gaze centers and on to the
nuclei of the third, fourth, and sixth cranial Vergences
nerves to innervate the extraocular muscles. Each Vergence refers to disjunctive eye movements, or
occipital lobe is involved in the pursuit of a tar- rotation of the eyes in opposite directions. The
get, in both directions, horizontally or verti- two main types of vergence movements are
Chapter1
Occipital Lobes
fl
Left Right
U J
U
LLR LMR RMR RLR
trolled to some degree, but they usually are
involuntary psycho-optic reflexes.13 Vergence
movements are slow and show a negative expo-
nential waveform (velocity diminishing from fast
to slow). For most visual tasks, both vergence and
saccadic eye movements are used
in combina-tion to place objects on
the foveas.
Little s known about the supranuclear pathways
subserving vergence eye movements, although
convergence n the monkey was produced as early
as 1890 by electrical stimulation of sites in the cor-
14
tex. Vergence eye movements probably are syn-
15
thesized bilaterally n the cerebral cortex (Figure
1-9). Impulses travel from the cortex to the pretec-
tum and rostral mesencephalic reticular formation.
Innervation is integrated from several sites, includ-
ing the cerebellum. In the midbrain, convergence is
mediated by the bilateral nuclei of the oculomotor
nuclear complex (cranial nerve III) that sends effer-
ent signis to both medial rectus muscles. There is
probably no single convergence center, contrary to
what once was believed (the so-called "nucleus of
FIGURE 1-7Hering's law and Sherrington's law evident during levo-
Perlia"). Regarding vergences, it s not certain
version. The right medial rectus (RMR) and the left lateral rectus (LLR)
ivoked muscles) contract, in accord with Hering's law. The left medial whether Hering's law of equal innervation of yoke
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.
Visual and
Cerebral
Pathways
Midbrain
and
Pons
NYI
Extraocular
Muscles
MR i
LR
Nnr
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.)
muscles s the operative principie. In the real (mainly n the calcarine fissure) located bilaterally
world, vergence stimuli often are presented asym- on the medial aspect of each occipital lobe.
metrically to the eyes, and asymmetric responses Other functions of the primary visual cortex (V1,
have been found by cise inspection.16 Henee, formerly Brodmann's rea 17) include detecting
each eye appears to be responding independently spatial organizaron of the visual scene, bright-
to that eye's view of the target. Therefore, vergence ness, shading, and rudimentary form organiza-
testing can be done using symmetric stimuli (e.g., tion. Specific points of the retina connect with
Risley prism procedure) or an asymmetric stimulus specific points of the visual cortex (e.g., the
(e.g., step prism procedure). homonymous right halves of the two respective
Divergence once was accepted as merely the retinas connect with the right visual cortex). In
relaxation of convergence innervation. However, other words, the primary visual cortex is orga-
divergence usually is an active neurophysiologic nized like a map of the retina. Because the eyes
process, as indicated by electromyographic record- are separated by a distance of approximately 60
ings from the lateral rectus muscles.17 The path- mm in humans, each eye's view of the environ-
ways that subserve divergence remain essentially ment is from a slightly different perspective. The
unknown. sol basis for stereopsis is the horizontal disparity
SENSORY ASPECTS OF BINOCULAR between the two retinal images. A little-under-
VISION stood neural mechanism presumably located
within the visual cortex compares the retinal
The ability to intgrate Information from the two
images from each eye for disparity information.
eyes into one fused image and to extract depth
Further neural processing in this visual pathway
Information depends on the primary visual cortex
(also not fully understood) gives almost all people
Chapter 1 11
with normal binocular visin a vivid sense of corresponding retinal points are sufficiently
three-dimensionality (e.g., volume) n their visual stimulated.
perception of the external world.
Binocular visin seems so natural to most peo- Panum's Fusiona! reas
ple that they are hardly aware that their perception Rather than a point-to-point correspondence
of the world arises from the unification of two sep- between the two eyes, there exists a point-to-area
rate and slightly different images. Most people are relationship subserving binocular fusin. This rela-
surprised f diplopia occurs. What s truly remark- tionship was first described by Panum, a Danish
able, however, s that we usually do see single physiologist, in the middle of the nineteenth cen-
imagesa fact that requires an explanation. tury.18 Panum's rea s "an rea n the retina of one
Fusin of two ocular images requires adequate eye, any point of which, when stimulated simulta-
functioning of each eye and sufficient stimulation neously with a single specific point in the retina of
of corresponding retinal points n the two eyes to the other eye, will give rise to a single fused per-
produce single binocular visin. cept."10 Panum's reas are oval and larger horizontal
ly than vertical ly. Foveal Panum's reas are very
Monocular Considerations small, only a few minutes of are, as compared with
peripheral Panum's reas, which may be several
For normal binocular visin, the best possible
prism diopters n extent. The ncreasing size of these
visual acuity of each eye should be attained,
reas n the periphery may be related to anatomic
whether by means of spectacle lenses, contact
and physiologic differences known to exist between
lenses, surgical ntervention (e.g., to correct for
central and peripheral retina, receptors being
cataract), or other possible treatments (e.g., visin
densely packed at the fovea but widely separated n
therapy for amblyopia). Poor acuity of either or
the peripheral retina. Panum's reas parallel the
both eyes s a deterrent to sensory fusin. This s
increase in size of the retinal receptive fields, but
particularly true when the visin of one eye s
they are functionally part of the visual cortex, where
much poorer than that of the other eye. The dis-
binocular information comes together.
crepancy may be due to such functional reasons
as anisometropic amblyopia and strabismic
Sngleness Horopter
amblyopia, or it may be due to organic causes,
Sensory fusin can also be described in terms of the
such as macular degeneraron, cataract, and optic
location of stimuli n the visual environment. The
nerve atrophy. Any organic disease must be ruled
horopter s defined as the locus of all object points
out or managed correctly before functional test-
that are imaged on corresponding retinal elements
ing s continued and visin training techniques
at a given fixation distance.19 The dentical visual
are begun.
direction (IVD) horopter s a locus of object points
n which images on the two retinas give rise to a
Retinal Correspondence common visual direction. The IVD horopter usually
Retinal correspondence refers to the subjective is represented as a single horizontal line passing
visual direction and the spatial location of objects through the fixation point and having no thickness.
n the binocular visual field. An individual s said The concept of Panum's fusional reas is easily visu-
to have normal retinal correspondence when the al ized by reference to the IVD horopter that is
stimulation of both foveas (and other geometri- enveloped by the haplopic (singleness) horopter.
cally paired retinal points) give rise to a unitary The haplopic horopter s "an empirical horopter
percept. (The correspondence actually occurs n represented as having thickness corresponding to
the cortex, but clinically it is easier to concept- Panum's reas expressed by the anteroposterior lim-
ale retinal points.) The existence of correspond- ts through which a nonfixated test object may be
ing retinal elements with their common subjective displaced and still be seen as single (Figure 1-10).10
visual direction s fundamental to binocular visin. Note that the horopter is thicker in the periphery,
Stimulation of corresponding retinal points results corresponding to the increasing size of Panum's
n haplopia (singleness of visin), whether corre- fusional reas. The significance of the singleness
spondence s normal or anomalous. (Anomalous horopter, which nvolves the IVD horopter and
retinal correspondence s discussed in Chapter Panum's reas, s that any object seen outside the
5.) Conversely, double visin results when non- horopter necessarily falls on diplopia-producing,
12 Chapter 1
diplopia
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 sin-
gleness horopter can be seen as double if sufficient FIGURE 1-11Homonymous ("uncrossed") physiologic diplopia.
(f = fovea.)
attention is paid to the stimulus object. Homony-
mous physiologic diplopia (also called "uncrossed"
diplopia) occurs when objects are beyond the point
of bifixation. Conversely, heteronymous ("crossec/") tor must explain that this is a feature of normal
diplopia occurs when a farther object is bifixated binocular visin that is normally not noticed.
with a nearer object in view (Figures 1 -11 and 1 -12). Some patients are not easily convinced of this
Because of physiologic suppression, these physio- physiologic fact about binocular visin because
logic diplopic images usually are unnoticed under the phenomenon seems counterintuitive. None-
ordinary viewing conditions. theless, physiologic diplopia s easy to demn-
Most patients consider seeing double to be strate to a patient with normal binocular visin
abnormal and seek help from an eye doctor. If the and can be used as a binocular visin screening
examination does not reveal a paretic muscle or a technique: As a patient fixates a pencil at 40 cm,
motor fusin problem and physiologic diplopia for example, the clinician asks the patient to hold
seems the most likely explanation, then the doc- up an ndex finger halfway between the fixation
Chapter1 13
Pathologic Diplopia
Diplopia of a fixated target, or pathologic diplo-
pia, s considered abnormal. It occurs n cases of
strabismus in which there is little or no suppres-
sion. 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 diplo-
pia 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 cyclo-
pean eye is compared with a clock's face, the
principal visual direction would occur at the
fovea (assuming normal fixation and correspon-
dence). In Figure 1-13, assume that the nasally
stimulated portion of the right eye is at the 7-
o'clock position. The directional projection is,
therefore, at the 7-o'clock position n the cyclo-
pean eye. The difference of "1 hour" would nor- FIGURE 1-12Heteronymous ("crossed") physiologic diplopia. (f =
mally cause noticeable diplopia (assuming one fovea.)
image s not suppressed). When, however, the
difference is only a very small fraction of an
"hour," diplopia may not be obvious, as n fixa- unlike either of the stimulating fields." 10 Color
tion disparity. (Fixation disparity measurement is fusin is independent of the singleness horopter. It
discussed in Chapter 3.) is the lowest level of sensory fusin and s of rela-
tively little importance, except that many visin
testing and training methods use color fusin (e.g.,
Types of Sensory Fusin
Worth dot test and anaglyphic targets).
Sensory fusin may be that of color or form.
Form Fusin
Color Fusin
Binocular fusin of forms occurs within the single-
Color fusin is "a type of sensory fusin wherein ness horopter, whereas diplopia occurs outside the
spectral stimulation which differs for the two eyes horopter. Fused binocular visin is precious, but it
s combined or integrated into a unitary percept is possible only in a relatively small band of visual
14 Chapter1
For any patient being treated for binocular anoma- As with other neuromuscular abilities, the health
lies, the ultmate goal is the achievement of clear, and vigor of specific visual-motor skills required
single, comfortable, and effcient binocular visin'. for everyday tasks vares considerabiy among indi-
Visual ski lis efficiency (VSE) s the term applied to viduis. Normative data collection has indicated
the ways n which various ocular systems oprate that most oculomotor and binocular visin skills
over time and under various viewing conditions. are distributed in a population along a normal
Clinical evaluation of visin efficiency necessitates bell-shaped curve. Some people are well suited
the assessment of sufficiency (amplitude), facility for intensive visual activity such as p rolonged
\WQ\\\tj\ acawaq, wb stamm oi each ocular pev\ods o readmg or computer work, whereas
function. others ave not Occupatiom and veaea \\ona\
Practitioners in the nineteenth century were activities vary tremendously in their requirements
concerned almost exclusively with clearness of for efficient visual skills. The visual work require-
eyesight and with lenses that would optimally ments of an attorney and computer programmer
reduce or elimnate blurred visin. Clearness and are much more intensive than those of the average
singleness of binocular visin became the issue farmer and sales clerk. Full-time computer opera-
with the advent of orthoptics. Effective therapeutic tors have come to expect some eyestrain and dis-
regimens for strabismus were introduced by Javal1 comfort as part of their job. Several studies have
and were expanded later by others. shown that the prevalence of visual symptoms
Astute clinicians in the first half of the twenti- increases with increased visual demands. Sensitiv-
eth century became aware of the relationship ity to visual and other forms of stress also differs
between accommodation and vergence. Knowl- among individuis, so a psychological dimensin
edge of the zone of clear, single, comfortable influences the manifestation of symptoms as well.
binocular visin was gained through various Henee, at least three factors interact to define a
models of visin, such as the graphical analysis visin efficiency dysfunction: (1) a patient's physi-
approach, and through an understanding of fixa- ologic level of visual skills, (2) specific visual
tion disparity (see Chapter 3). requirements (how visin is used), and (3) sensitiv-
In the latter half of the twentieth century, more ity to visual stress. The clinician must eval ate
and more emphasis was placed on efficiency of these factors when obtaining a patient's case his-
visin, implying that effcient visual skills are tory and performing the examination.
related to good scholastic abilities (school) and The oculomotor and binocular visual skills that
occupational production (work) and to achieve- have been widely implicated in dysfunction are
ment in sports and hobbies (play). As a result, (1) deficient pursuit tracking; (2) deficient saccadic
lenses or functional training techniques frequently tracking, particularly in reading; (3) overstressed
are applied in clinical practice to help patients or deficient accommodative skills; (4) excessive
attain efficient binocular visin in these activities. heterophoria (esophoria, exophoria, and hyper-
(Surgery is not a mode of therapy commonly asso- phoria); (5) deficient or overstressed vergence
ciated with visin efficiency therapy.) skills; and (6) deficient sensory integration and ste-
Fundamental to having good VSE is the opti- reopsis. The relationships among accommodation,
mum correction of any significant refractive error. vergence, and sensory fusin skills have been a
Clinicians have found that correcting even small focus of optometric research and practice since
errors of refraction can result in large changes in the 1930s and encompass classic heterophoria
visual comfort, stamina, and performance. If a case analysis and fixation disparity analysis (cov-
patient presents with a significant refractive error, ered in Chapter 3). These historie approaches are
a visin efficiency evaluation ideally should be part and parcel of visin efficiency analysis, but
performed with the new lens correction in place, testing and evaluation of oculomotor and binocu-
if necessary using a trial frame spectacle correc- lar visual skills have evolved to include efficiency
tion. Normative data presented in this chapter considerations of how a patient's specific skills
assume that refractive error has been corrected. respond over time and relative to specific tasks or
Dysfunctions of visual skills also result from a conditions. In a society of increasing educational,
mismatch between a patient's oculomotor and occupational, and recreational demands on
binocular physiology and the environmental visin, the testing and evaluation of VSE has taken
demands placed on the individuaos visual system.
center stage.
Chapter 2 21
PATIENT HISTORY one's place; (4) laborious or slow reading; and (5) the
need to use a finger or ruler as a place keeper. (See
The most mportant and revealing component of Appendix I, Visual Symptoms Survey.)
the history is the chief symptom. Intense eye pain
and prolonged double visin are not symptoms
commonly associated with visin efficiency dys-
MALADAPTIVE BEHAVIORS
functions and usually indcate more severe and
acuite disorders. Vision efficiency dysfunctions, Preschool and elementary school children rarely
particularly in adults, often are associated with report visual symptoms, even in cases of frank
symptoms related to visually demanding activities visual dysfunction. On careful examination, some
at near distances, such as reading, writing, sewing, are found to have significant dysfunctions by stan-
and computer use. The symptoms usually increase dardized clinical criteria but, when asked, they
in ntensity with ncreased time devoted to the task seldom admit to any visin problem. As observed
and abate with sleep or rest. n cases of early-onset myopia, n which reports of
Asthenopia applies to symptoms of ocular blurred visin are also rare, young children do not
fatigue or discomfort. The common symptoms of have a standard for comparison. They believe that
tired eye with sustained visual activity should be what they are experiencing visually, for better or
distinguished from reports of general fatigue. Tired worse, is normal and expected. Children also rap-
eyes do occur as part of chronic fatigue, systemic idly modify their behavior when they do encounter
diseases (e.g., hypothyroidism and other endocrine difficulties. With careful questioning of a child,
mbalances), allergy attacks, and general stress parents, and teacher, the clinician often finds that
reactions. Clinicians are often challenged to make the child compensates or maladapts by demon-
the distinction between ocular fatigue and general strating avoidance behavior, a short attention span,
fatigue, because each can contribute to manifesta- and distractibility, and develops a dislike for the
tions of the other. A carefully obtained, detailed activity causing discomfort. To compnsate for a
patient history may be necessary but sometimes binocular visin problem, a child might hold read-
still is nsufficient. ing material very cise to enlarge the print, shut or
Headaches can be causes of or exacerbated by cover an eye with a hand, or lay his or her head on
dysfunctions of accommodation or vergence or the upper arm to disrupt binocular fusin. Some
both. However, headaches are attributable to children learn to hold the head up and turned to
many different medical and psychological etiolo- one side so that the nose can act as an effective
gies, and so differential diagnosis is necessary. occluder. Using one's hand to shade the eyes from
Ocular headaches usually are described as a dull overhead lights provides some relief when over-
to modrate ache at the brow line, around the sensitivity is present (e.g., from a mild nflamma-
eyes, or emanating from the orbits. Other locations tion of the eyes). Rather than conducting a
may be mplicated, particularly the back of the problem-based examination of a child, the clini-
head and neck, which are also associated with cian must take a proactive approach to history tak -
general stress. Vision efficiency dysfunctions have ing for behavioral maladaptations and then
also been known to initiate a m igraine headache undertake a thorough examination, including mea-
in sensitive individuis. sures of visin efficiency.
Reports of intermittent blur, doubling, or "wob-
bling" of print are also common and are highly asso-
ciated with disorders of accommodation and
READING DYSFUNCTION
vergence. Except for symptoms associated with track-
ing dysfunctions, pinpointing specific conditions Do visual skill deficiencies adversely affect reading
associated with specific symptoms is difficult. The performance? Does visin therapy for visual skill
symptoms associated with accommodative and ver- dysfunctions result n mproved comfort, reading
gence dysfunctions often overlap. Saccadic tracking efficiency, and reading performance on standard-
dysfunctions, however, often result n definitive signs ized tests? These are mportant and somewhat con-
and symptoms. In such cases, patients report (1) skip- troversial questions. The American Academy of
ping over words, parts of words, or sentences; Ophthalmology and the American Academy of
(2) inadvertent rereading of a line of print; (3) losing Pediatrics drafted a position statement denying any
22 Chapter 2
relationship between visual conditions (save uncor- hyperopes must use accommodative effort to bring
rected refractiva error) and reading disabilities. The a distant mage into clear focus on the retina, thus
mplication is that visin therapy s ineffective and requiring additional and often excessive accom-
a waste of remedial time.2 This statement s ambig- modation to clear print at the preferred reading
uous in that the term "reading disability" can be distance. These facts suggest that the amount of
interpreted to mean dyslexia, a neurologically accommodative effort is associated with reading
based disorder in word decoding, or t can be inter- performancea relationship that has been con-
preted to mean any significant reading problem firmed by other studies.
from other causes. The American Optometric Asso- As part of the meta-analysis, Simons and
ciation, n collaboration with other optometric Gassler5 found several other conditions associating
organizations, have issued their own position state- disorders of fusin with poor reading: Among poor
ment arguing that several visual conditions aside readers, there was a high prevalence of (1) ani-
from refractive error are associated with poor read- sometropia, in which different refractive errors in
ing performance and not necessarily dyslexia.3 (See the two eyes presented an obstacle to binocular
Appendix A for text of statement.) Furthermore, integration of the images; (2) aniseikonia, in which
visin therapy s a recognized and effective thera- different image sizes in the two eyes posed as an
peutic intervention for improving or curing visin obstacle to fusin; (3) excessive exophoria and
efficiency dysfunctions. In cases n which such hyperphoria, eye teaming conditions that stress
therapy s applied, improved reading performance fusin skills; and (4) fusional vergence deficiency
often occurs. However, visin therapy techniques or restricted vergence skills. The common feature
for visual skill deficiencies are not intended to cure among these conditions is emphasis on an individ-
dyseidetic or dysphonetic types of dyslexia.4 Both ual's sensory fusin capacity and vergence system,
visin specialists and the public at large need which keeps the eyes in alignment for nearpoint
authoritative information on these issues, due to the tasks. Asthenopia and quick visual fatigue usually
obvious important mplications for school visin are the consequences. This association with poor
screening and because of the serious social con- reading skills implies that the symptoms or mal-
cern regarding improving students' reading perfor- adaptive behaviors are severe enough to influence
mance across the nation. reading progress, although a direct causal relation-
Many studies have sought an association between ship has not been established.
visual conditions and reading performance. As one Grisham et al.6 have found a significant, although
might expect, these studies vary considerably in weak, correlation between reading test scores and
their subject groups, tests of reading and visin, the number of visual symptoms that college stu-
and quality of research design and analysis. One dents reported. Generally, the more symptomatic
statistical approach used to evalate a large num- the students were, the poorer was the reading per-
ber of studies with varying design features s called formance, and vice versa.
meta-analysis. Simons and Gassler5 used this tech- Assessment of VSE should include both sensory
nique in evaluating the results of 32 controlled and motor functions of the eye. We recommend test-
studies that used valid tests for visin conditions ing of five eye movement and fixation systems:
and reading performance. Good reading perfor- (1) saccades, (2) pursuits, (3) position maintenance,
mance was found to be associated with uncor- (4> vestbulo-ocular reflexes (VOR), and (5) vergences
rected myopia. The tested students, as a group, (aside from accommodation). Sensory fusin and
read better than did emmetropic students requiring stereopsis are the final goals of accurate and efficient
no spectacle correction. In uncorrected myopia, binocular alignment of the eyes; henee, they should
the farpoint of accommodation (the punctum be ncluded n a comprehensive evaluation.
remotum) resides at a near distance, so less accom-
modative effort is required for reading. Distant
visin s mpaired, but the eyes are optically in
focus at some near distance f the amount of near-
SACCADIC EYE MOVEMENTS
sightedness is approximately equal in each eye Saccadic eye movements are abrupt shifts in fixa-
and is not severe. In contrast, poor reading was tion and are classified as fast, as compared with
found to be strongly associated with uncorrected pursuit and vergence eye movements.7 A good
hyperopia (i.e., farsightedness). In these cases, clinical average velocity is approximately 300
Chapter 2 23
degrees per second, which s approximately 10 What are the symptoms of either organic soft-
times greater than the velocity of pursuit and ver- sign or functional saccadic dysfunctioning? Several
gence movements (approximately 30 degrees per performance problems may be evident f saccadic
second).8 Saccadic eye movements are mainly eye movements are poor, even though the patient
voluntary, the other eye movements being mainly s otherwise considered neurologically normal.
involuntary. The duration and velocity of a sac- Inefficiency in reading is a major problem and s
cade are proportional to the magnitude of the eye frequently reported n such cases. Words may be
movement. For example, a 40-degree sweep omitted, lines may be skipped, or loss of place may
would have a greater velocity and a longer dura- occur often during reading. "Finger reading" may
tion than would a 5-degree sweep. The velocity of indcate the need for hand support due to poor eye
a saccade changes during its course, being faster movements. Head movement when reading is
at the beginning and slower toward the end of the another common sign of poor saccades. The
sweep. Although this may be shown in the labora- patient may present with a history of "having trou-
tory, its observation clinically s difficult, even ble hitting the ball" or "doing poorly in many ath-
with recording instruments such as the Visagraph letic events." Job performance may be affected
isee Appendix J). 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 Objective Testing
visin turns off as a saccadic eye movement is Clinicians should evalate saccadic eye move-
occurring. This makes sense; otherwise, the world ments using both gross and fine tasks. Fine sac-
would appear to be a swimming, blurry mess as we cades are those nvolved in reading (approximately
sean our environment. This perceptual inhibition, 7 degrees or less). Larger saccades than these are
which has been called saccadic "blindness," is considered gross. A patient's saccadic eye move-
more aptly named saccadic suppression. According ment skills can be evaluated either on an objective
to Solomons,9 each saccadic eye movement is pre- or a subjective basis.
ceded by a latent period of approximately 120-180 Any target, such as small letters on two pencils,
milliseconds before the eye movement actually can be used to test for gross saccadic ability. The
begins, and saccadic suppression begins to occur patient s asked to look voluntarily from one target
approximately 40 milliseconds before the move- to the other. This usually is done n right- and left-
ment commences. The inhibition ncreases until gaze orientations, but vertical as well as oblique
visual perception is almost zero during the first part orientations can be tested. If one of the patient's
of the movement. Probably not until after the sac- eyes is occluded, testing s for saccadic ductions. If
cadic movement has ended does the saccadic sup- both eyes are open, testing s for saccadic versions.
pression completely cease. It should be noted that even behind an occluder,
The first differential diagnostic issue for consider- the covered eye moves conjugately with the uncov-
ation s whether a pathologic etiology s present ered, fixating eye. A difference may be noted, how-
when deficient saccadic eye movements are found. ever, in the performance of one eye as compared
If voluntary versions are severely restricted, the cli- with the other during duction testing. This possibil-
nician should suspect neurologic problems affect- ity s an important consideration n therapy, as the
ing the saccadic pathway, such as myasthenia, patient should, f possible, have equal saccadic
vascular disease, or tumors that may affect supranu- skills in both eyes.
clear control. Other signs of neurologic dysfunc- Gross saccades are used in general environmen-
tioning would likely be evident n such cases. tal scanning to direct fixation to a point of interest.
Many times, however, only subclinical "soft" signs They can be initiated by reflex stimuli or by voli-
are present, with the patient appearing to be nor- tion, so both stimulus modes are employed n
mal n all other respects. Many patients have func- screening. Because reading requires finer control of
tional saccadic problems, such as those from poor saccades than s sampled by such screening tests,
attention, hyperkinesis, or poor visual acuity due to these procedures are more appropriate for evaluat-
uncorrected refractive errors, and possibly because ing saccadic skill n general scanning and in sports
saccadic skills were never learned adequately. performance. The patient is asked to stand free of
24 Chapter 2
support in front of the clinician and is instructed to horizontal saccadic eye movements is as follows:
particpate in a penlight game: "Look only at the A target with a letter printed on it that is approxi-
light that is on, not at the light that is off." The clini- mately equivalent to 20/80 (6/24) acuity demand s
cian then holds two penlights approximately 10 cm placed to the patient's right side. A similar target is
apart at a distance of 40 cm from the patient. placed to the patient's left. The targets are sepa-
Directing the beams away from the patient's eyes, rated by approximately 20 cm and are held at a
the doctor alternately flashes the lights in a random distance of 40 cm from the patient. (In the past, 25-
pattern to elicit "reflex" saccades. The patient wins cm separation was recommended, but separation
the game if he or she does not make a mistake and greater than 20 cm is not always feasible without
look at the "off" light through 10 randomized the need for some head movement.) The patient is
cycles. Most children, age 6 and older, who follow asked to move his or her eyes alternately to each
a normal developmental pattern can complete this target approximately 10 times. The clinician
task with three or fewer errors, show good saccadic should look for naccuracies (i.e., either under-
accuracy, and exhibit minimal head and body shooting or overshooting). Scoring the results of
movement. Children having attentional difficulties observation is on a 4+ basis, as follows: 4+ f
often cannot play this game successfully. Children movements are accurate, 3+ if there is some
in whom oculomotor coordination development is undershooting, 2+ if there is gross undershooting
mmature and adults having neurologic conditions or any overshooting, and 1+ if there is either
show saccadic undershoots or overshoots and inability to perform the task or an increased
excessive head and body movements. latency. A score of 2+ or less is considered failing,
"Voluntary" (volitional) saccades are sampled in a as would be any uncontrolled head movement.
similar way. Still standing, the patient is instructed to Hoffman and Rouse10 considered a failure on
look back and forth from one light to the other 10 this basis to indcate a need for referral for visin
times and as quickly as possible; both lights are now therapy for saccadic dysfunctioning. Whether or
on. The clinician counts aloud as the patient per- not referral s actually made, failure of the SCCO
forms the task. Observations indicating immature or test, which demonstrates poor saccadic skills,
defective voluntary control of saccadic fixation should alert the practitioner at least to consider the
include (1) inaccuracy of saccades (undershoots and possibility of advising visin therapy. In other
overshoots); (2) mltiple intervening saccades; words, clinical judgment is required; referrals for
(3) slow alternation (longer than 2 seconds per visin therapy are not automatic merely on the
cycle); (4) lack of rhythm in the alternating pattern of basis of a single poor test result.
fixation; (5) motor overflow, indicated by facial Two alphabet pencils may be used in the man-
movements, particularly jaw and eye brow move- ner described earlier (Figure 2-1). However, the
ments; and (6) excessive head and body movements young child cannot be expected to proceed all the
(greater than a few degrees). This screening test is way through the alphabet; rather, the patient
quite good at identifying those school-aged children should be allowed to read the "A" on each pencil.
who have immature oculomotor skills and who have For an adult, one pencil can be turned to expose
not made the developmental shift from making pre- the Z, Y, X . . . sequence. A task of A-Z, B-Y, C-X,
dominantly head movements to eye movements. and so on, is demanding and checks for false
Immature gross saccadic tracking is a prodromal sign reporting as the patient looks from one alphabet
of tracking difficulties in reading and writing. How- pencil to the other. This is because verbalizing the
ever, just because a child shows good gross saccadic alphabet in reverse sequence without seeing the
maturity does not necessarily mean that tracking for letters is difficult (see Figure 2-1).
reading material is also adequate to the task. Further-
more, we have seen deficient gross saccadic tracking Heinsen-Schrock System
even as reading eye movements appear to be nor- A 10-point scale is another system created by Dr.
mal, although this finding is infrequent. Arthur Heinsen and Dr. Ralph Schrock (A. Hein-
sen, R. Schrock, personal communication, 1981).
Southern California College of It can be performed with alphabet pencils (previ-
Optometry System ously described). For example, the patient can
A quick and simple routine used at the Southern receive 3 points if there is no head movement, 2
California College of Optometry (SCCO) for testing points if saccades are accurate, 2 points if sac-
Chapter 2 25
Ophthalmography (Visagraph)
A traditionally used clinical ophthalmographic test
for recording reading saccades was the Eye-Trac.
However, this instrument s no longer manufac-
tured. In ts stead, the Visagraph (Figure 2-2) has
become the standard ophthalmolophic testing
nstrument. An ideal target s a five-dot card (Figure
2-3), designed by Walton and tested by Griffin et
al.,11 who analyzed the eye movements of 25 sub-
jects during reading and fixation tasks using a pho-
tographic recording nstrument. The previously
selected subjects included 12 adequate readers
and 13 inadequate ones. Griffin etal.11 concluded,
"
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 movement-
recording system used in conjunction with a per-
sonal computer for analysis of the eye movement
record. Taylor Associates (see Appendix J) designed
this instrument for clinicians and educators to eval-
ate an individual's eye movement characteristics
during the act of reading standardized selections of
print and for analysis of saccadic control indepen-
dent 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 fixa-
tion (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, sev-
era! 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 com-
puter eye movement profile and the original graph
can be inspected relative to several detailed oculo-
Chapter 2 27
motor ndices of performance: excessive number of cadic ability must be performed quickly, as there is
fixations, number of regressions, prolonged average no permanent printout for later analysis. Judgments
duration of fixation, rate in targets per minute, sac- are strictly qualitative and lack precisin. Notwith-
cades in return sweeps, and cross-correlation of the standing these drawbacks, experience goes a long
two eyes, a possible measure of vergence accuracy way in making this procedure useful n the event
(Figure 2-6). Although normative data have not been that either the Eye-Trac or Visagraph is not available
published to date, Taylor Associates offer clinical at the time of testing. Sequential fixation tests are
guidelines for evaluating oculomotor performance of colloquially called a "poor person's ophthalmo-
children and adults (see Figure 2-4) for graphic exam- graph." The practitioner can increase clinical acu-
ples of good and poor sequential saccadic perfor- men with this simple testing procedure by
mance on the five-dot card. comparing results with those obtained by ophthal-
mographic recording instruments.
Sequential Fixation Tests Whether the Eye-Trac or Visagraph is used, the
Another reading saccade test that is objective but patient should also be tested while reading sen-
much less sensitive than the Eye-Trac and Visagraph tences and paragraphs. Figure 2-8 shows relatively
is the use of printed cards, such as the five-dot test, poor and good reading saccades; the patient was a
for which the clinician directly observes a patienfs more efficient reader after saccadic visin training.
eye movements to evalate dot-to-dot saccades. Testing with cognitive (paragraph) and noncogni-
These sequential fixation tests come in a variety of tive (five-dot) visual stimuli can suggest a differen-
forms. The dots (or other symbols such as asterisks, tial diagnosis between purely saccadic problems
stars, numbers, letters, and words) may be printed and cognitive problems (e.g., dyslexia, poor com-
on a clear actate sheet so that the clinician can prehension, or unfamiliarity with certain words).
look directly at the patienfs eyes through the
printed sheet to observe inaccuracies and head
movements (Figure 2-7a). Another variation is an Subjective Testing
opaque card on which the symbols are printed and Saccades may also be evaluated indirectly by sub-
in which a center hole allows the clinician to jective means rather than directly by objective
observe the patienfs eye movements (see Figure 2- observations. The following tests are examples of
7b). Obviously, in such a test, assessment of sac- subjective methods.
Chapter 2
2 1 S 4 ^
M * . . _/ * * * * ^ J
JL <J
"JL** t t
^
fc^*# *******
7
*<M** ******
*
*H/*
1
****ftJL******
^ 1
*^*-*.*^
^
FIGURE 2-5The numbers test used
4 1 ^ 2 1 4 ^ with the Visagraph. The purpose s to
nr JL ******^<*****M** assess binocular and tracking accu-
JLTr/ racy. (Courtesy ofTaylor Associates.)
JL * ^w ** t ^m JL JL "
Chapter 2 29
Fixations/100 numbers
Regressions/100 numbers
to side. Holding the card too cise invaldales the Once the demonstration is completed, the first
test, as very large saccades would be demanded; of three subtests is begun. This s a timed test,
therefore, the patient should hold the card at a dis- and a corrected score, using the following for-
tance of approximately 40 cm. A demonstration s mula for each subtest, takes into account the
given initially so that the patient can start with the errors:
number at the upper left crner of the page and fol-
Corrected time score = 30 / 30
low the arrow to the number on the upper right cr-
- errors x time in seconds
ner, then follow the arrow for the return sweep to the
number on the left-hand side of the page, and so The total of the three corrected scores s deter-
forth. The room should be well lluminated for test- mined and compared with the norms to judge the
ing purposes. patient's chronologic age equivalence (Table 2-2).
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 sac- that subtests II and III were too difficult for many 6-
cadic efficiency between ages 6 and 13, whereas year-old children, and so only subtest I is recom-
beyond age 13, improvement is minimal. mended; it was found to have norms of 30.98 seconds
with 1.32 errors for 6-year-old children. The King-
King-Devick Test
The King-Devick test, a derivation of the Pierce
test, was devised with fine saccades in mind. It
contains five numbers per line, and the numbers
are randomly spaced, supposedly simulating sac-
cades that occur in the act of reading. Scores are
TABLE 2-2. Sample of Normative Vales for the
Pierce Saccade Test
Cheonofcgic Age
I
evaluated in terms of errors and time; they then are Corrected Time Scores Expected
compared with normed scores according to chro- (secs)
nologic age, in a manner similar to that used in the
Pierce saccade test. The authors of the King-Devick 6 150 125 100
test concluded that poor saccadic ability contrib- 7 82
utes to poor reading ability.13 8 70
Samples of approximate norms determined by 9 65
Cohn and Lieberman14 (in a study in cooperation 10 59
with a New York Optometric Association team) are 55
given in Table 2-3. Subjects were 1,202 students n 12
regular public schools. Cohn and Lieberman14 found 13
Chapter 2 31
3 4 3 75 9 8
7 5 2 5 74 6
5 2 1 4 7 6 3
9 1 7 9 3 9 2
8 7 4 5 2 1 7
2 5 5 3 7 4 8
5 3 7 4 6 5 2
7 7 9 2 3 6 4
4 4 6 3 2 9 1
6 g 7 4 65 2
1 7 5 37 4 8
4 4 4 52 17
7 6 7 93 9 2
6 5 1 4 7 6 3
3 2 2 57 46
7 9 3 75 9 8
9 2 b
3 3
9 6
2 4
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 abil- 1. Both the vertical time and the adjusted hori
ity for sustained performance (stamina). zontal time are normal. This is considered
Visual stamina and attention in performing sac- normal performance.
cadic tests have been found to be important factors 2. The vertical time is normal but the adjusted
in distinguishing those students who fail the DEM horizontal time is abnormally increased.
test and those who pass.16 More errors were made This indicates "oculomotor dysfunction"
in the second half of the horizontal test by the fail- and, presumably, poor horizontal fine sac-
ing students. cadic eye movements.
Similar to the Pierce test, the DEM test uses a 3. Both the vertical time and the adjusted hori
formula to determine "adjusted" time: zontal time are abnormally increased but are
approximately the same. This indicates a
Adjusted time = test time x 80 / (80 - O + A) problem in automated number calling rather
than a saccadic deficiency (i.e., RAN problem).
where test time is the actual time for number call- 4. Both the vertical and horizontal times are
ing on the horizontal array, O represents omission abnormal, but the horizontal is much worse.
errors, and A indicates addition errors (numbers This indicates both a RAN problem and a
being either repeated or added). saccadic eye movement deficiency.
The essence of the DEM test is to compare the In evaluating symbol tracking using the DEM
test results of vertical time with horizontal time. test, both the speed of tracking (the ratio ndex)
Four outcomes are possible: and accuracy (the number of additions and omis-
Chapter 2 33
TEST A TEST B T E ST C
3 4 6 7 3 7 5 8
7 5 3 9 2 5 7 4 6
5 2 2 3 1 4 7 6
9 1 9 9 7 9 3 9 O
2
8 7 1 2 4 5 1 7
2 5 7 1 5 3 O7 4 8
5 3 4 4 7 4 6**^ S 2
7 7 6 7 9 2 3 6 4
4 4 5 6 6 3 2 0 1
6 8 2 3 -* 4 6 5 2
1 7 5 2 5 3 7 4 8
4 4 3 5 4 5 2 1 7
7 6 7 7 7 9 3 9 2
6 5 4 4 1 4 7 6 3
3 2 8
4
6 2
3
G7 7 4 6
7 9 3 5 9 8
9 2 5 7 TIMI sec
3 3 2 5 J_ _s <y o errors
9 5 1 9 errors
_a / t errors
-L.
FIGURE 2-11 Example of resuits errors
TIME 80
2 4 7 8 ADJ
from a 1 0-year-old patient who passed = TIMEx
(80-o + a)
the vertical subtest of the Develop-
mental Eye Movement Test (36% or
J ADJ T1ME= / sec ,*;
higher s passing) but failed as to errors
(5%), horizontal time (10%), and ratio
21 sec
TOTALTIME: 4/ sec
(/<TOTAL ERRORS (s + o + a
+ 1)
HORIZONTAL ADJ TIME / *O S-.es \
=_z_/>#;
(5%). This suggests poor saccadic eye ADJ TIME '^ s e c ^ O <) VERTICAL ADJ TIME =** T^(***)
movements but reasonably good auto- ERRORS: /
maticity. ' RATIO = -
sions) must be considered. Normative data are sion errors within a line of numbers also suggest
provided for subjects of ages 6-13 years. Chil- inaccuracy, but verbal errors can also explain addi-
dren should have a good knowledge of numbers tions, transpositions, and substitutions (e.g., mis-
1-9, which most do by age 6 years. However, calling a 9 for a 6). The clinician must use
attention ski lis and ability to deal with detail judgment when evaluating saccadic accuracy
seem to be lacking in many 6-year-old children. rather than relying entirely on the total error norms
Therefore, we recommend that such subjects be listed in the test manual. (Figure 2-11 shows an
asked to complete only half the vertical and hori- example of DEM test resuits for a patient, with per-
zontal tests and that the examiner then double centile ranks for vertical and horizontal tests, ratio,
the times and errors before applying the norma- and errors.)
tive analysis. Furthermore, the DEM test s too
difficult for most kindergartners. 17 Nonetheless, Maples Oculomotor Test
the DEM test, specifically the ratio ndex, can be Dr. W. C. Maples19 has produced, n our opinin,
used reliably with Spanish- as well as English- the best standardized and normed set of oculomo-
speaking students.18 tor tests based on the clinician's gross observa-
Accuracy can be evaluated by noting the pattern tions. The testing protocol and scoring are too
of errors a child makes. Whole lines skipped or elabrate to be presented here, but the test s avail-
added usually reveal saccadic inaccuracy. Omis- able from the Optometric Extensin Program Foun-
34 Chapter 2
TABLE 2-4. Ordinal Ranking Method of Visual Skills TABLE 2-6. Modification of the Heinsen-Schrock
System for Testing and Rating Saccadic Eye
Movements for a 5-Point Mximum Score
Rank Description
lows: (1) SCCO 4+ system, (2) sequential fixation viewing conditions), whereas binocular viewing
testing, and (3) DEM test. conditions allow for testing of pursuit versions.
(Versions, as with ductions, may be saccades, pur-
suits, or nonoptic eye movements.) Regardless of
Summary of Saccade Testing
the fact that an eye may be occluded, the covered
The clinician should attempt objective testing of
eye moves conjugately with the fixating eye under
saccadic eye movements even when electro-oph-
most normal circumstances.
thalmography (Visagraph) is not available. This can
Defective pursuit eye movements, seen n many
be accomplished, for example, with the SCCO 4+
elementary school children, may be attributable to
system, the Heinsen-Schrock system, and sequential
lack of development (immaturity), lack of experi-
fixation tests. When subjective and indirect assess-
ence (untrained), or lack of attention. In many cases,
ment s performed, the DEM test accounts for defi-
pursuit exercises seem appropriate and effective n
ciencies in RAN skill, which must be distinguished
remediating this oculomotor dysfunction. Inatten-
from poor saccadic skills. Unless the RAN s known,
tive children may benefit also from visin therapy,
the practitioner s unable to ascertain whether poor
but usually other techniques are necessary. In
horizontal saccades are due to RAN problems or
adults, however, the absence of smooth pursuit
are due to actual saccadic deficiencies. It s desir-
tracking s predominantly an indication of neurologic
able to convert scores into a ranking system so that
dysfunction. Deficiencies n pursuits, for example,
there s a common denominator for each visual skill
have been found in patients experiencing schizo-
function. We propose a 5-point ordinal ranking sys-
phrenia,24'25 cerebellar degeneraron,26 Parkinson's
tem that s easy to understand and convenient for
disease, and many other neurologic degenerative
patient communication purposes.
conditions. Interestingly, Thaker et al.24 reported
Most of the testing procedures described in this
poorer predictive pursuits n schizophrenic subjects
section are appropriate for patients 7 years and older.
than in normal control subjects, even when effects
Some children between the ages of 5 and 6 are able
of antipsychotic medications were taken into
to respond to some of these tests, but n patients
account.
younger than 5 years, the clinician must rely on gross
There may be neurologic "soft signs" in the case
and objective methods, such as the SCCO 4+ system.
of jerky pursuits. Problems may be so subtle that
no lesin can be found (by radiology or other
means) along the occipitomesencephalic pathway.
PURSUIT EYE MOVEMENTS In some cases, functional training techniques may
A pursuit eye movement s defined as a "move- help. In many others, however, not much can be
ment of an eye fixating a moving object."21 done to improve pursuits when a neurologic
organic etiology exists. Nevertheless, differential
diagnostic testing should be considered. For exam-
Characteristics ple, assume a patient has normal voluntary sac-
According to Michaels,22 pursuits are unlike sac- cades but pursuit movements that are significantly
cades n that visin is present (without suppression, restricted and jerky: A supranuclear lesin affect-
as n saccades) throughout the eyes' excursions. The ng the occipitomesencephalic pathway would be
speed of pursuits s limited to approximately 30 suspected. In contrast, if saccades are inaccurate
degrees per second. They may be considerably and restricted but pursuits are normal, a fron-
slower but not much faster. If the target velocity is tomesencephalic pathway lesin s suspected.
too high, the pursuits break down into a jerky It s always wise to check both pursuits and sac-
motion. The attempt to keep tracking requires the cades on a routine basis, not only to determine
faster saccadic responses to come into play in order gross organic defects but to detect subtle problems
for the patient to regain fixation of the target. In that can handicap individuis because of resulting
infants, pursuit eye movements start to manifest at inefficiencies of visin. Additionally, drugs, fatigue,
approximately 6 weeks of age and increase n tn- emotional stress, and test anxiety may adversely
dem with the development of sustained visual atten- affect pursuit performance. For example, we have
tion to moving targets.23 examined many children with reading difficulties n
Pursuits are a form of duction eye movements whom we found a "midline hesitation" during con-
when only one eye s being tested (monocular frontation pursuit testing using a penlight, although
36 Chapter 2
Up gaze
TABLE 2-7. Heinsen-Schrock System for Testing
and Rating Pursuit Eye Movements, Modified for
5-Point Scale
Ten-Pont Five-Point
Patient's Patient's Scale Scale
Right _ _ Left
gaze gaze
Smooth, always on target 3 1.5
Smooth, sometimos off target 2 1.0
Jerky, generafly on target 1 0.5
Jerky, generally off target O 0.0
B
Down gaze Free of head movement 3 1.5
Head movement, but can 2 1.0
inhibit
FIGURE 2-12British flag pattern from clinician's view (lines indicat-
Slight head movement persiste 1 0.5
ng movements of penlight) for testing pursuits with the Southern Cali-
fornia College of Optometry 4+ test. Obvious persistent head O 0.0
movement C
Automated pursuits 3
Reduced automation 2 1.5
no irregularity in pursuit function was found using 1.0
laboratory electronic tests. On follow-up clinical Much reduced automation 1
No aytomation O 0.5
testing, our initial findings were repeatable. This 0.0
mystery was solved when we discovered that if we D
moved to the patient's side, the "hesitation" also Adequate stamina for 1 mn 1
Stamina for less than 1 mln
0.5
moved toward that side. The children evidently 0.0
were making eye contact with the examiner, possi-
bly because of being apprehensive in the clinical
testing environment. This example points out the smooth and fixation is always accurate, 3+ if
importance of distinguishing between true pursuit there is one fixation loss, 2+ f there are two fixation
dysfunction and poor tracking induced by inatten- losses, and 1 + if there are more than two fixation
tion, lack of cooperation, or test anxiety. losses. The patient is considered to have pursuit
problems if the score s 2+ or less. If there is any
obvious head movement during testing after the
Testing of Pursuit Skills patient has been instructed notto move the head,
Several objective and subjective testing procedures performance is considered to be inadequate. The
are discussed as examples. The tests are basically right eye, the left eye, and then both eyes should
the same, in that they al I allow for monitoring the routinely be tested for pursuits by eye care
accuracy of pursuit eye movements. practitioners, whether by this or another method.
However, the SCCO method lends itself to testing of
Direct Observation patients of all ages, ncluding infants and young
A quick and convenient testing and rating system for children.
pursuits on a 4+ scale is used at SCCO.10 A fixation
target approximately the size of a 20/80 (6/24) letter Heinsen-Schrock Scale
is moved n front of a patient at a distance of approx- Heinsen and Schrock(A. Heinsen, R. Schrock, per-
imately 40 cm to extents of nearly 20 cm from pri- sonal communication, 1981) introduced a rating
mary gaze. The target is moved left-right-left (one system (the H-S Scale) for pursuits that is similar to
cycle), up-down-up (one cycle), and in two diagonal that for evaluating saccades (discussed previously).
orientations (one cycle each), as in the lines of a Brit- This 10-point scale is shown in Table 2-7. Our 5-
ish flag, with the patient being instructed to track the point ordinal ranking system also is shown, to
target (Figure 2-12). A 4+ is given if pursuits are allow comparison of the very strong to very weak
Chapter 2 37
Afterimages
Afterimages can be used in conjunction with a
moving target to provide visual feedback for the
patient and to determine whether tracking s accu-
rate. This technique is useful n both testing and
training. An afterimage may be used for a single
eye for monocular testing, or both eyes may be
stimulated simultaneously for binocular pursuit
testing. The same type of afterimage generator used FIGURE 2-13Bernell Rotator Trainer with elephant on the disk.
for testing anomalous correspondence can be used (Courtesy of Bernell Corp.)
for these purposes (see Chapter 5).
iques might help patients with pursuit problems. are believed to be useful for the purpose of correct-
As mentioned previously, the testing procedures ing fixational errors, to keep the fixated target pre-
for pursuits encompass some voluntary aspects cisely on the fovea, and possibly preventing retinal
(e.g., head movement, automation, and stamina). adaptation (fatigue).
These aspects can be improved and made more Position maintenanc can be assessed by asking
reflexive, starting from volition and progressing to the patient to fixate (monocularly) on a target.
automation. In many cases, accuracy and smooth- There should be no noticeable drifting or eye
ness are improved as a result of functional training movement from the target of regard. If the patient
techniques. In patients in whom the pursuit prob- cannot maintain steady fixation, he or she should
lem is of functional etiology (e.g., due to inatten- be instructed to hold a thumb at 40 cm to deter-
tion), the prognosis for mprovement is favorable. mine whether the proprioceptive input from the
"hand support" is helpful in maintaining steady
Summary and eye positioning. The problem may persist (e.g., due
to congenital nystagmus). If the problem is psycho-
Recommended Tests
logical (e.g., lack of attention) or from other known
Clinical assessment is important for identifying causes (e.g., fatigue or drug effects), improvement
neurologic problems and dysfunctional visual of position maintenanc often is possible through
tracking (particularly relevant to sports perfor- appropriate environmental changes and the efforts
mance). The SCCO 4+ test is recommended for use of functional training techniques.
by primary eye care practitioners in routine cases. The vast majority of patients show steady fixa-
Pursuit tests should usually include monocular tion ability with each eye. Unsteady fixation of
(duction) as well as binocular (versin) testing. one eye can be seen in some cases of amblyopia
Functional and organic causes should be differen- or decreased monocular visual acuity from other
tiated. Some patients may require "diagnostic ther- causes. Saccadic intrusions are unconscious,
apy" to determine whether the identified problem rapid, bidirectional flicks of fixation off a target
abates as a result of visin training. Practitioners and back on. These intrusions may be a present-
choose their favorites from among the available ing sign of a neurologic disorder. They look like
testing procedures. For example, a recently intro- square-wave, to-and-fro "darting" movements of
duced test for pursuits, devised by Dr. W. C. the eyes on attempted fixation. Small saccadic
Maples, is becoming popular (see the section Sum- intrusions, from 1 to 5 degrees, can be seen in the
mary of Saccade Testing). elderly; in patients with dyslexia, strabismus, or
schizophrenia; and in patients who are extremely
fatigued. However, larger saccadic intrusions, 5
FIXATION to 20 degrees, can be associated with degenera-
Fixation (known also as position maintenanc) tive conditions such as mltiple sclerosis.
involves all four eye movement systemssaccades,
pursuits, nonoptic (e.g., VOR) system, and ver-
gences. Fixation evaluation usually is accomplished Southern California College of
toward the beg'mning of an eye examination (e.g., Optometry 4+ System
during the unilateral test). Assessment s made as the The SCCO 4+ system is a quick and easy test for posi-
patient fixates on a target in primary gaze. tion maintenanc.10 The patient is instructed to fixate
Figure 2-14 shows Eye-Trac recordings of good a target approximately the size of a 20/80 (6/24) letter
versus poor position maintenanc. Reading diffi- E at a distance of 40 cm. The left eye is occluded for
culties and various symptoms may occur with poor testing of the right eye; afterward, the left eye is tested
position maintenanc. and, then, binocular testing is undertaken. Testing
True position maintenanc is actually a misno- time is at least 10 seconds per eye. The quality of
mer, in that very small movements are occurring all steadiness is assessed as follows: 4+ if steady for at
the time during so-called steady fixation: The eyes least 10 seconds, 3+ if steady for at least 5 seconds,
are not motionless during fixation. Ocular micro- 2+ if steady fewer than 5 seconds or if hand support
movements consist of rapid flicks and slow drifts of is needed, and 1 + if fixation is unsteady almost con-
a vev\ sma\\ ampVvtude that are not observable tinuously. A 2+ or 1+ is considered failing as criteria
without special equipment.TViese sma\\ movements ior poss\b\e refeua\. NAodtf\cat\on oi the SCCO 4+
Chapter 2 39
Functional etiology
Binocular: deficient accommodation due to biolgica! variation in th populaton, excessive nearpoint work, low Illu-
mination, 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, iridocy-
clitis, 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, vas-
cular 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
accommodative amplitude in each of the three for the dimimshed accommodation was suggested
patients was practically zero, but we doubt if that had by history or could be identified by careful examina-
ever been tested. The resumption of wearing plus- tion. All patients were successfully managed opti-
addition bifocals solved their problems, and no fur- cally with bifocals or reading glasses, although three
ther treatment was necessary. We saw another required the addition of base-in (Bl) prisms because
29
patient, a 21-year-old college student, who had only of exophoria at near. Ciuffreda stated that the main
1 diopter (D) of accommodative amplitude but exhib- symptom of accommodative nsufficiency s general
ited no other physical signs or symptoms. She had asthenopia related to near work.
contracted influenza 3 months previously but main- Convergence nsufficiency s commonly associ-
tained a 4-hour-daily swimming schedule on a swim ated with accommodative i nsufficiency, as is
team. Bifocals were prescribed to relieve her near- accommodative infacility. Other symptoms besides
point visin problems, and a subsequent neurologic nearpoint blur that are frequently reported by these
evaluation revealed a low-grade viral encephalitis. patients include headaches, eyestrain, diplopia, and
30
The most prevalent cause of accommodative reading problems.
nsufficiency is functional (Le., a mismatch between
a patient's physiologic accommodative capability Absolute Accommodation
28
and his or her work requirements). Chrousos et al. The amplitude of accommodation s measured
described 10 detailed cases of healthy young people monocularly using the push-up method for one eye
who reported intermittent blur at near. They demon- and then the other. This is absolute accommoda-
strated amplitudes of accommodation considerably tion. The print size should be equivalent to 20/20
lower than those expected for their respective ages (6/6) at 40 cm, or smaller or larger depending on
(an average reduction of 6 D). No organic etiology the patient's mximum visual acuty. The mximum
Chapter 2
first sustained blurpoints. Failure on the PRA test is a from the patient. This distance s converted into
32
sustained blur for 5 seconds with lens powers weaker diopters to determine the accommodative lag. The
than -1.75 D (relative to CAMP lenses). In other patient fixates reading material at 40 cm (2.50-D
words, passing requires clear and sustained visin accommodative stimulus) while retinoscopy s per-
with -1.50 lenses. Failure on the NRA s similarly a formed through a hole in a card (Figure 2-15). The
sustained blur with lens powers weaker than +1.75 clinician physically moves toward the patient until a
D. Clinicians should bear in mind that relative neutralized reflex is observed, say, at 67 cm (1.50-D
accommodation often is limited by deficient ver- accommodative response). The accommodative lag,
gence ranges. For example, an esophoric patient with according to the Nott method, would be 1.00 D in
a high accommodative convergence-accommoda- this example. This test s done while the patient is
tion ratio and with poor fusional divergence will behind the refractor.
likely have a reduced PRA. With the Nott method, the accommodative stimu-
lus does not change, because the testing distance is
Lag of Accommodation kept constant, and no dioptric changes are made by
Although t does not necessarily imply insufficient the intervention of additional lenses. The nearpoint
amplitude of accommodation, lag of accommoda- rod of the refractor can be used to measure directly
tion can be thought of as a clinical form of accom - the dioptric distance between the fixation distance
modative insufficiency for a particular nearpoint and the retinoscopic neutralization distance (i.e., the
target. Accommodative lag can also be thought of distance representing the accommodative lag).
as accommodative inaccuracy, just as fixation dis-
parity can be considered to be an inaccuracy n Monocular Estmate Method Retinoscopy
vergence. Lag of accommodation can be measured When testing is performed outside the refractor,
in several ways, but two of the most reliable clini- monocular estmate method (MEM) retinoscopy may
cal methods are described here. be more convenient than the Nott method. The MEM
s called "monocular" despite the fact that the patient
Nott Method has both eyes open and testing s conducted under
33
The Nott dynamic retinoscopy method is based on binocular viewing conditions. The MEM of Haynes
the linear difference between the fixation distance is similar to the Nott method except that the retino-
(usually 40 cm) and the distance of the retinoscope scopic distance is kept constant. This s often at the
Chapter 2
Harmon distance (distance equal to that from the tip suggests the possibility of anomalies of insuffi-
of one's elbow to the middle knuckle of the clenched ciency of accommodation, infacility of accommo-
fist measured on the outside of the arm).21 Distances, dation, and ill-sustained accommodation, any of
however, may vary, as the patient's habitual reading which can be adverse factors in visin efficiency.
distance is recommended. The binocularly viewing Ranking of either Nott or MEM results s shown n
patient s instructed to read appropriate material (for Table 2-13. A rank of 2 or 1 s failing, and referral
his or her age or cognitive level) mounted on the reti- for visin therapy may be recommended.
noscope. A trial lens s quickly interposed in the
spectacle plae of one eye to neutralize the retino- Excess of Accommodation
scopic reflex (Figure 2-16). The lens s removed from
Another inaccuracy s accommodative excess,
the eye within a second, because latency of accom-
sometimes called spasm of accommodaton, hyper-
modation response is short. Tucker and Charman34
accommodation, hypertonic accommodation, or
found a mean reaction (latency) time of 0.28 second
pseudomyopia. Accommodation may be excessive n
for one subject and 0.29 second for another. There-
focusing on a stimulus object and is considered to be
fore, 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 TABLE 2- 13. Ranking of Accommodative Lag
before the eye for a longer duration. The possibility of (Insufficiency, or Inaccuracy, of Accommodation)
changing accommodative responses by changing
accommodative stimuli must always be kept in mind
when one is conducting the MEM test. Nott or MEM Retinoscopy
The lens power (addition of plus) necessary to of Accommodation (OD Lag
achieve retinoscopic neutralization is the esti- Rank Description or OS)
5 Very strong +0.25 D
mated accommodative lag of the eye being tested
at the moment. If minus power should be required 4 Strong +0.50 D
for neutralzation, accommodative excess would 3 Adequate +0.75 D
be indicated. 2 Weak +1.00D
Using the Nott or MEM procedure, we believe 1 Very weak +1.25D
an accommodative lag of 1.00 D or greater is MEM = monocular method; OD = oculus dexter;
cause for further investigaron. This concern was stimate
OS = ocultis sinister.
shared by Bieber.35 A high lag of accommodation
Chapter 2 45
36
Liu et al. suggested that the criterion for passing 18 cycles per minute, as compared with 15 cycles per
be 20 cycles per 90 seconds, allowing each cycle to minute for the subjects having poor visual skills. Bin-
take 4.5 seconds or each flip to last 2.25 seconds. ocular rock without suppression monitoring gave
37
Griffin et al. studied monocular accommodative averages of 17 and 9 cycles per minute for the same
facility n 14 subjects ranging in age from 20 to 35 two groups, respectively. When binocular rock was
years. They found 2.00-D rock to have an average tested using suppression monitoring, there was an
valu of 17 cycles per minute. The average response average of nine cycles per minute for the subjects with
time to clear the minus lens was 2 seconds, whereas good visual skills but only four cycles per minute for
1.4 seconds were needed to clear the plus lens. those having poor visual skills. The authors concluded
38
Griffin et al. determined monocular facility as that binocular accommodative facility testing can be
compared with binocular facility. They wanted to definitive n the assessment of a patient's binocular
elimnate the possibility of guessing and ensure that status.
39
patients were actually seeing clearly rather than Burge used a practical clinical method to study
reporting "clear" with each lens flipping. Instead of binocular facility using suppression monitoring. He
manually changed targets (which were double-digit used a Spriangle Vectogram (see Appendix J) target
numbers), an electrical mechanism introduced ran- with crossed polarizing viewers and 2.00-D lens
dom numbers (of six-point type size at a distance of flippers. The mean valu results were 12 cycles per
40 cm) in synchrony with the lens flipper mechanism. minute monocularly, 10 cycles per minute binocu-
Rock of +2.00 D was conducted for 1 minute to larly without suppression monitoring, and 7 cycles
determine the average number of cycles n a young per minute with suppression monitoring. Burge's
adult population, ages 20-23 years. Monocular facil- valu for monocular facility was lower than those
37 38 39
ity was approximately 17 cycles per minute. Binocu- obtained by Griffin et al. ' However, Burge
lar facility was approximately 13 cycles per minute, included younger subjects among his test group
without monitoring of suppression. To monitor sup- (ranging n age from 6 to 30 years).
40 41
pression, a vectographic pate was arranged so that Grisham and Pope et al. established monocular
the leftward (first) digit was seen only by the left eye accommodative facility norms for elementary
and the right eye saw only the second digit. For exam- school children and validated these norms by objec-
ple, the number 53 that appeared with the new lens tive accommodative testing. They tested second,
change would be presented so that only the number 5 fourth, sixth, and eighth graders using 2.00-D flip-
could be seen by the left eye and the number 3 by the pers at 33 cm. The target was a 20/30 optotype, and
right eye. There were only six cycles per minute as an each child was asked to report when the print
average for this group of subjects when suppression appeared to "clear" with each lens. The norms
was monitored. The nvestigators reviewed the 27 proved to be the same for all children except for the
records of complete visin examinations and selected second graders, whose responses were often inac-
16 subjects who showed evidence of poor visual skills curate, presumably due to lapses of attention. The
and 11 who showed good visual skills. Monocular researchers measured the time the subjects took to
rock for the subjects with good visual skills averaged complete 10 cycles and 20 cycles on the test.
48 Chapter 2
TABLE 2-76. Ranking of Accommodative Facility with tive facility. These criteria do not apply to children
2.00 Diopters younger than 7 years. Professional judgment must
be used when evaluating accommodative facility
in very young children.
Cycles per Minute
Ill-Sustained Accommodation
Rank Description OD or OS Binocular* Testing for ill-sustained accommodation is similar to
5 Very strong 4 >18 >10 that for facility of accommodation. Ill-sustained
Strong 3 14-18 8-10 accommodation relates to stamina, or the power to
Adequate 2 10-13 6-7 endure fatigue.42 It is easily detected in most routine
Weak 6-9 4-5 accommodative facility testing, which is why clini-
1 Very weak <6 <4 cians should carry out facility testing over a period
OO = oculus dexter; OS = oculus sinister. of at least 1 minute. Speed and sufficiency may be
*Suppression montorng with vectographic targets. normal in the beginning but may be maintained
only with effort and will decrease with time. The
time during which stamina diminishes may be short,
often within 1 minute. For example, a patient with
Because no significant difference in cycles per ill-sustained accommodation may begin 2.00-D
minute was found, they recommended using 10 lens rock quickly and sufficiently, but the responses
cycles for testing children age 8 years and older. The may become inadequate after a few flips of the
mean time was 52 seconds, with a standard devia- lenses. If the clinician tests for only one or two
tion of 24 seconds. A unique feature of this study cycles, the patient's lack of accommodative stamina
was the objective verification of the clinical proce- may not be discovered.
dure. The properties of accommodative facility Ill-sustained accommodation can affect perfor-
(latency, velocity, and completion time) were objec- mance and result in various visual symptoms. Indi-
tively measured using a dynamic optometer in ran- viduis vary widely in their ability to meet and
domly selected subjects. The rank correlation sustain accommodative demands for a variety of
between the clinical and objective measurements reasons (e.g., physiologic variation, medication,
was high (r - 0.89), indicating good concurrent visual demands, and general health). Clinical expe-
validity. (Other studies are shown in Table 2-15.) rience has shown, however, that accommodative
There is no consensus on developmental norms stamina can be improved in most cases in which
from childhood to adulthood for accommodative the cause is functional in nonpresbyopic patients.
facility. As to referral criteria for facility, Hoffman Therapy is the same as for accommodative facility.
and Rouse10 recommended the following: flipper Monocular, biocular, and binocular accommoda-
test of 2.00 D monocularly and binocularly tive rock procedures are performed in the office
showing less than 12 cycles per minute, with the and at home. The only difference is that sustaining
patient viewing a 20/30 Une at 40 cm, or a differ- ability is emphasized to a greater extent than other-
ence of more than 2 cycles per minute between wise. (Therapy is discussed in Chapter 15.)
the two eyes. In light of the results shown in Table For testing of accommodative stamina, we rec-
2-15, these referral criteria may be too stringent, ommend using the ranking shown in Table 2-17.
especially for young children. Retesting or lowered These are clinical empiric observations; fully
initial standards should be considered during the researched norms await further reports. The clini-
routine testing of new patients. We recommend cian flips the lenses at a constant rate, 6 seconds
the following cutoff criteria for failing such a test: A per cycle. If this rate is maintained for 36 seconds
subject is considered to have failed the test if under binocular conditions, the patient passes
monocular facility is less than 10 cycles per this recommended standard for accommodative
minute or if the difference between the eyes is stamina. Stability is emphasized, as opposed to
greater than 2 cycles per minute; failure also is rec- frequency of correct calis as in facility testing. It is
ognized if binocular facility with suppression mon- one thing to be fast for a while but, in real life, an
itoring is less than 6 cycles per minute. Table 2-16 individual will not do well if he or she lacks stam-
provides clarification and ranking of accommoda- ina. This is as true for the accommodative system
Chapter 2 49
will have a breakpoint several centimeters from the Note that the 2.7-cm distance is the approximate
spectacle plae. (Refer to Table 2-18 for ranking distance from the center of rotation of the eyes to
criteria.) After the blurpoint is reported (although the spectacle plae (Figure 2-19).
not reported by many patients) and the breakpoint
is measured, the target is withdrawn in a similar Functions and Norms for
manner and at the same speed to determine the Absolute Convergence
point of recovery. Supplementary testing in up- NPC testing allows assessment of three functions
gaze and down-gaze may be included as war- of absolute convergence: sufficiency (amplitude),
ranted (e.g., in cases of A or V patterns). (See the facility (flexibility), and stamina. Norms listed
discussion on comitancy in Chapter 4.) below are from Griffin,43 Hoffman and Rouse,10
These clinical measurements usually are recorded and our clinical experience.
in centimeter vales, although they may alternately
7cm
2.7 cm
Sufficiency of absolute convergence is deter- most likely has significant binocular problems, and
mined by the usual testing method of pencil push- referral for visin therapy should be considered. In
ups, as described earlier, although a small detailed summary, the evaluation of stamina, as well as
target s recommended rather than a pencil tip. The facility and sufficiency of absolute convergence, is
blurpoint is so variable among the normal popula- important.
tion that norms have not been established. Ideal ly, Although NPC normative data are not well
however, blurring should not occur until the target established for infants and preschoolers, practition-
approaches a distance n the range of 10-15 cm. In ers of visin therapy are well aware that infants of
contrast, the breakpoint should be much less 1 year of age can converge their eyes to view a tar-
remote, normally 7-8 cm or closer. Either diplopia get at very cise distances. Wick44 reported this in
of the target (as reported by the patient) or loss of a patient not quite 1 year od.
bifixation (as observed by the examiner) at a dis-
tance exceeding 8 cm is considered "failing," Developmental Considerations
which can be used as a cutoff point for referral Absolute convergence, as measured during NPC test-
considerations (seeTable 2-18). Certainly a remote ing, s composed of Maddox's four components:
NPC greater than 10 cm is a failing test result. tonic, accommodative, proximai, and fusiona! ver-
The reporting of diplopia s a subjective test. gence. The developmental period of each of these
Subjective NPC results should be corroborated components differs and should be taken into account
with objective test results (observation of exam- by clinicians examining infants and toddlers.
iner). Ordinarily, direct observation of the patient's Schor45 summarized that tonic vergence is stim-
eyes will suffice, but greater accuracy s possible ulated by intrinsic innervation, accommodative
by observing the corneal reflexes from an auxiliary vergence responds to blur, and psychic vergence
penlight source held a few centimeters above the depends on perceived distance. These are "open-
letter f fixation target, a modified Hirschberg test. loop" responses and do not demand much of
(See Chapter 4 for discussion of Hirschberg test- visual feedback mechamsms. For example, one
ing.) Suppression may be indicated if there is no eye may be occluded, but convergence will occur
report of diplopia and the clinician observes a lack f the unoccluded eye responds to the accommo-
of bifixation. dative demand of a minus lens, which would
Facility of absolute convergence can be assessed cause accommodative convergence. Fusiona! (dis-
indirectly by the patient's ability to recover bifix- parity) vergence, on the other hand, is a "closed-
ation. Only singleness, not necessarily clearness of loop" response requiring sensory feedback from
the target, s demanded for normative evaluation retinal image disparity. Tonic vergence can be
purposes. The patient should be expected to recover measured at birth and s often a "low tonic" con-
singleness (and recurrence of bifixation should be vergence resulting n an exo deviation. Accommo-
objectively observed by the examiner) at a distance dative vergence is evident, to some extent, within
of 10-11 cm or closer as the target is withdrawn. a few weeks after birth. Prxima! convergence s
Poor vergence recovery is indicated if the distance is evident n the neonate as shown by the difference
more remote. In other words, a recovery beyond 11 between the deviation in lighted surrounds (usu-
cm s considered "failing," and referral for visin al ly exo deviation) and the deviation of the visual
therapy should be considered (seeTable 2-18). axes in darkness (usually eso deviation).
Stamina of absolute convergence is assessed by According to Schor,46 however, "It s clear that the
repeating the break and recovery testing four binocular disparity vergence system s the last of the
times, for a total of five routines. Poor stamina is oculomotor functions to develop. Little is known
ndicated f the endpoints are more remote on rep- about the age at which the response s adultlike."
etition. Any decrement in performance over this The following section on disparity vergences, there-
period s considered failing or, at least, s sugges- fore, presents established norms for adults. We
tive of a dysfunction of gross convergence. Note believe these are applicable also to older children
that the training effect of repeated NPC testing may and perhaps to those as young as 7 years. Although
result in prism (vergence) adaptation, which theo- children are physiologically capable of responding
retically should help the patient to converge more to testing, attentional problems may cause unreli-
sufficiently. If, however, sufficiency s reduced on able results n many cases. Nevertheless, our clini-
repetition because of lack of stamina, the patient cal impression is that a 7-year-old child should have
52 Chapter 2
approximately the same magnitudes of sufficiency, Clinical testing of relative vergence should begin
facility, and stamina of vergence functions as do with divergence testing. This is so because prism
older children and adults, assuming that attention is adaptation to BO is relatively strong and prism
good and optimal performance is attained during demands may contamnate the Bl findings, making
testing. In general, testing of very young children the fusional divergence response appear falsely
must be objective to a large extent. much weaker than otherwise. According to the
hypothesis of Schor,46 ". . . [T]he stimulus to ver-
Relative Convergence gence adaptation is the effort, or output, of the fast
fusional vergence controller." In other words, the
Testing and Norms
reflex-disparity-vergence output resulting from Ris-
Convergence is the term traditionally applied to ley BO prisms can induce prism adaptation during
both convergence and divergence. However, in actual clinical testing. Therefore, fusional diver-
discussions of relative vergences, the general term gence testing should precede testing of fusional
vergence probably is preferable to inclusin of convergence. By tradition in clinical practice, how-
the semantically restrictive prefix con-. Use of ver- ever, farpoint Bl and BO vergence testing precedes
gence would avoid the need for awkward or nearpoint Bl and BO vergence testing. The clinical
superfluous denotations such as negativa fusional sequence is (1) fusional divergence at far, (2) fusional
convergence and positiva fusional convergence. convergence at far, (3) fusional divergence at near,
The terms relative vergence, fusional vergence, and (4) fusional convergence at near. Despite the
and disparity vergence may be used interchange- possible contaminant of prism adaptation (espe-
ably for most clinical purposes. (Refer to Chapter cially with BO prism), clinicians find it more con-
3 for further discussion on relative vergences.) venient to finish farpoint testing before moving on
The stimulus for fusional vergence eye move- to nearpoint testing. Therefore, we recommend
ments is ret'mal disparity, with other intervening maintaining the traditional sequence, for the sake
variables excluded: This means that a constant of clinical ease and expediency.
testing distance is maintained during increasing
prismatic stimuli. Relative vergence is conve-
niently measured from the orthophoric demand Fusional Vergences at Far
point, which simplifies clinical recording. For Fusional divergence at far is also. known as nega-
example, a patient views a target at 40 cm while tive fusional vergence, negativa fusional conver-
base-out (BO) demand is increasingly introduced gence, and negativa disparity divergence, among
with Risley prisms.The blurpoint, breakpoint, and other designations for this function. For the sake
recovery point are recorded directly from the of consistency and historical precedent in this
scale on the instrument as though the patient (and text, we adhere to negative relative convergence
every patient) is orthophoric. The actual magni- (NRC} at 6 m as the clinical nomenclature of
tude of the disparity vergence response, however, choice. The stimulus to fusional divergence is ret-
must take into account the fusion-free position of 'mal image disparity (which is Bl demand). The
rest, which involves the effects of tonic, accom- responses of tonic, accommodative, and proximal
modative, and proximal vergence. If, for example, vergences must be minimized, to the extent possi-
a patient has exophoria of 6A at 40 cm and the ble, so that only fusional vergence is measured.
blurpoint with BO demand is 10 A, the total Fusional divergence can be measured by several
fusional (disparity) vergence response would be clinical methods. The most common method for
16A. Suppose another patient has an esophoria at measuring NRC is by the use of Risley prisms in a
40 cm of 4A: The total fusional (disparity) vergence phoropter. From a distance of 6 m, the patient is
response would be only 6 A for the 10 A BO instructed to view a vertical column of letters, nor-
demand. This method of measurement compli- mally of 20/20 (6/6) acuity demand, but the letter
cates establishment of norms for clinical useful- size may vary depending on the best attainable
ness. Conveniently, however, relative vergences acuity of the patient. If, for example, the patient's
measured from the common-denominator ortho- best corrected visual acuity is 20/40 (6/12), that
phoric position allow for standardizaron of particular mnimum angle of resolution for letters
norms. Henee, re/af/ve vergence is the preferred should be used for testing. For reliability of all
term and testing procedure for clinical purposes. visual skills testing, CAMP lenses for mximum
Chapter 2 53
Recovery to
Rank Description Bturpoint (A) Breakpoint (&) Singleness (4)
5 -~ Very strong >14 >24 >15
- A .' Strong 11-14 21-24 12-15
. 3: - - . Adequate 8-10 16-20 9-11
Weak 7 15 8
\ Veryweak <7 <15 <8
cm. The Bl demand is presented to the patient in zontal vergence facility of fusiona! divergence
the same manner as was discussed previously for and convergence.) Grisham40'47 studied the ver-
other fusiona! vergence testing. The blurpoint gence tracking rate, using 2 A jump-vergence
should be at least 12A for passing, the breakpoint steps in eight subjects, four of whom had "nor-
should be at least 20A, and recovery should be at mal vergence characteristics" and four of whom
least 11A. had "abnormal" heterophoric or vergence char-
Fusional convergence at 40 cm is conducted as acteristics, based on clinical data. Grisham
discussed earlier. BO prism demand is increased found that the group with normal vergence char-
gradually until the endpoints of blur, break, and acteristics had an average minimum stimulus
recovery are reached. The blurpoint is PRC. Pass- duration of 0.84 seconds per step, whereas the
fail criteria are shown in Table 2-22, along with group with abnormal characteristics had a signif-
rankings from very strong to very weak. A blur- icantly longer duration of 1.67 seconds per step.
point of less than 15A is failing, as is a breakpoint Grisham47 cited the observation of Rashbass and
of less than 19A and a recovery of less than 8A. Westheimer "that normal disparity vergence eye
These findings are entered in the patient's record. If movements take on the order of 1 sec to com-
a blur is not reported, place an X to denote this plete independent of step stimulus amplitude"
(e.g., X/18/7). and claimed that his study "compares well with
the observation of Rashbass and Westheimer."
Grisham also found that the two groups of sub-
Vergence Facility
jects could be differentiated according to other
Vergence facility depends on both amplitude dynamic properties of fusiona! vergence response,
and speed of vergence movements. The quantity including percentage of completion of step
and quality of disparity vergences should be responses, response velocity, and divergence
evaluated. (Discussion will be limited to hori- latency (but not convergence latency).
ique s that it s objective, relying only on tester subjective responses of sensory fusin (singleness
observations. It can be used to confirm subjective versus diplopia) by the patient may be helpful.
vergence testing or for patients who have unreliable Using 10 cycles of 6A BO, the norm s 22 seconds
subjective responses (e.g., young children, some 3 standard deviations and, for 6A Bl, it is 21 sec-
aged patients, and some handicapped patients). onds +4 standard deviations. Using the standard
The procedure is simple, but accurate observa- deviation as the basis for clinical evaluation, a
tion and interpretaron require practice. A 6A prism patient's vergence responses are considered slow f
is nserted before the sighting dominant eye as the the completion time s 25 seconds or longer.
patient fixates a target at 40 cm. In exophoric In many cases of vergence infacility, the com-
cases, convergence s evaluated first with a BO pletion time s considerably longer than 25 sec-
prism and then with a Bl prism. Conversely, with onds. Prolonged latency, slow velocity, and
esophoric patients, a Bl prism is used initially, fol- inaccuracy can all contribute to increasing the
lowed by a BO prism. Because the patient s view- total time. Some patients experiencing vergence
ing binocularly, the prism is a vergence stimulus. fatigue may not even complete the 10 cycles and
Usually, there is a mixed versin and vergence manifest diplopia or suppression during the test.
response to a small-mcrement prism. A normal Diplopia is noted subjectively by the patient's
vergence response would represent little or no report. Objectively, the clinician observes the
movement of the eye without the prism; most of patient's failure to make a correct vergence
the vergence movement would be by the eye with response. A suppression response is noted f there
the prism. The larger the response of the non- is no movement of either eye to the vergence
prismed eye, the longer is the latency of the ver- stimulus. In this case, the patient has suppressed
gence system. Velocity of the vergence component the eye behind the prism. In summary, a pro-
s directly observed and rated as slow, modrate, longed completion time, soiated versin, altr-
or fast on the basis of clinical experience with this nate versions, or no movement to the prism are
test. If there is one smooth vergence movement to all responses considered to be abnormal and
the prism, the response is considered accurate, indicative of a fusional vergence dysfunction.
whereas f a series of vergences are observed, inac- Kenyon et al.48 studied "dynamic" vergence
curacy is evident. Stamina can be noted by rapid, responses to stimuli at two different distances, 25
repeated observations of the speed and accuracy and 50 cm. They actually were testing fusional facil-
of vergence responses n a particular direction. ity of vergence, because disparity vergence was
An attempt to quantify the reflex fusin test has being tested as in "jump" vergences, in contrast to
been made by establishing norms for teenagers and "sliding" vergences, as tested with Risley prisms. An
adults. Ten cycles of prism rock are timed in a par- absence of disparity vergence was found in all stra-
ticular direction, BO or Bl. The clinician insers and bismic individuis and in some who had amblyopia
removes the prism when each vergence response s with no strabismus. Accommodative convergence,
completed. Direct observation of responses is the rather than fusional (disparity) vergence, was used
basis for reintroducing the prism but, in cases in to attempt to bifoveate the target.
which the responses are particularly slow and visu- From the literature and clinical experience, we
alizing the point of complete bifixation is difficult, believe clinical testing of vergence facility can be
56 Chapter 2
I
TABLE 2-23. Partial Listof Studies on Vergence Fadlity
useful in evaluating the quality of a patient's bin- Jacobson et al.54 studied vergence facility in 41
ocular status and, possibly, the patient's develop- young adults with no referable visin problems or
mental-perceptual status. Pierce49 reported a significant binocular problems. Two sets of Quoits
difference in vergence facility between normal vectographic targets were used, the upper pair having
and learning-disabled children. Other studies50'51 a Bl demand and the lower pair a BO demand. Test-
reported developmental differences between ing was done at 40 cm. A 5A Bl demand was pre-
schoolchildren in the third and sixth grades, the sented relative to the patient's nearpoint heterophoric
results being approximately 5 and 7 cycles per eye positioning. (A nearpoint phoria s also known as
minute, respectively, using 8A Bl and 8A BO flip- fusional supplementary convergence valu.) For
pers (Table 2-23). Moser and Atkinson52 found an example, f the patient had an esophoria of 4A at
average of 8.14 cycles per minute in young adults nearpoint, only 1A Bl was set n the upper Quoits
using 8A Bl and 8A BO flippers in vergence facility sudes. Similarly, a 15A BO demand relative to the
testing. Rosner53 proposed the following criteria near phoria was set in the lower Quoits slides, so
for screening (for referral): 6 A Bl and 12A BO that, in this example, the setting would be at 19A BO.
demands at farpoint and 12 A Bl and 14 A BO The investigators found it necessary to make these
demands at nearpoint. For ultmate goal, Rosner53 adjustments for the heterophoria because many sub-
suggested at least 18 cycles in 90 seconds at far- jects could not perform a range of 20A using absolute
point and nearpoint using free-space orthopic and 5A Bl and 15A BO demands. The principal problem
chiastopic fusin without instrumentation or fil- for many subjects was with Bl demands, particularly
ters. (These types of fusin are discussed in Chap- if the subjects were esophoric at near. A mean of 8.6
ters 13 and 14.) cycles per minute was found, which would indcate a
Chapter 2 57
TABLE 2-24. Vergence Fadlity Tested with 8A Bl TABLE 2-25. Vergence Stamina with 8A Bl and 8A BO at
and 8A BO at 40 cm and with 4A Bl 40 cm and with 4A Bl and 8A BOat6m at the Rate of
and8 A BOat6m
6 Seconds per Cycle
Vergence Stamina
Analogous to accommodative stamina, vergence
rather low recommended number for screening and stamina s tested when vergence facility s assessed
referral purposes. If absolute Bl and BO powers of 5A over a period of time at a constant rate of stimulus
and 15A, respectively, are used, we believe a screen- change. (Slowing of responses should be noted.)
ing criterion of 5 cycles per minute is useful as a cut- Vergence stamina s tested at 40 cm with 8A Bl and
off valu, particularly for children. A training goal, 8A BO demands at the rate of 6 seconds per cycle
however, would be much higher. (3 seconds per clear fusin response). The patient
Delgadillo and Griffin 55 found that 5 A Bl and is instructed to see the target as clear and single.
15 BO gave approximately the same results as 8A
A Testing at 6 m is performed with 4A Bl and 8A BO
Bl and 8A BO; therefore, either test can be used at flip prisms every 3 seconds, so hat testing is at the
nearpoint, at least n adults with normal binocular rate of 6 seconds per cycle. The cutoff point s 30
visin. seconds (Table 2-25). The patient should be able to
Considering the aforementioned reports and on maintain clear and single fusin with each flip for
the basis of our clinical experience, we recom- at least 30 seconds.
mend evaluating vergence facility as shown n
Table 2-24. For children of ages 7-11 years, a Summary of Vergence Testing
lenient cutoff criterion for failing s 4 or fewer As with accommodation, vergences are classified
cycles per minute; 5 cycles per minute or more as either absolute or relative and testing helps to
would be passing and would obvate the need for determine sufficiency, facility, and stamina. Accu-
referral for visin therapy. These criteria apply at racy of vergence is assessed with fixation disparity
40 cm with 8 A Bl and 8A BO prism demands as testing (discussed n Chapter 3), which s analo-
well as at 6 m with 4 A Bl and 8 A BO prism gous to accommodative accuracy as assessed with
demands. Although these criteria appear to be dynamic retinoscopy.
lenient, some of the earlier reports recommending
greater vales for cycles per minute did not
include suppression monitoring. We have found
SENSORY FUSIN
that patients general ly are much slower when vec-
tographic targets and viewing filters are used, From a clinical perspective, the systems of saccades,
reduced perhaps by as many as 3-5 cycles per pursuits, fixation, accommodation, and vergences
minute, whether n children or adults. We believe, are principally motoric. However, there must be
therefore, that the criteria in Table 2-24 can apply sensory (and usual ly perceptual and often cognitive)
to both children and adults for evaluation of ver- input so that visual functioning can occur. Clinical
gence facility. testing of sensory fusin also nvolves a motoric
Chapter 2
iponent. Nevertheless, for instructional pur-s, it in front of the deviating eye to elicit a diplopic
is convenient to deal with motor fusin and sensory response. If a sufficiently large base-down prism is
fusin as though they were seprate, keep-ing in placed before the right eye, the dioptric image of
mind that this distinction is artificial and that they the light is located below the suppression zone
are really indissoluble. (inferior retina) and will be perceived (in the visual
On a clinical basis, motor fusin can be consid- field) above the fixated one. When suppression is
ered basically to involve the amplitude and speed very deep, this technique is useful in determining
of various ranges of vergences. In contrast, the the horizontal subjective angle of deviation.
basic clinical concern in sensory fusin is suppres- Simultaneous perception testing may also be car-
sion. Sensory fusin is classified according to the ried out by using two objects rather than one. These
Worth taxonomy into three categories: first-, sec- targets usually are stereograms designed for use in a
ond-, and third-degree fusin. (Refer to Chapter 1 stereoscope. A familiar example is the Keystone
for theoretic discussions of these degrees of sen- Test 1 (referred to by the manufacturer as DB-10A),
sory fusin.) in which a picture of a pig is seen only by the left
In clinical diagnosis, sensory fusin of form can eye and a dog by the right eye. If the suppression
be classified into four levis, a modification of the zone is great and encompasses one picture, one of
categories of fusin recommended by Worth (as the animis will appear to be missing.
cited by Revell56):
TABL E 2-28. Verhoeff Stereopter Testing Distance TABLE2-29. Approxmate Corresponding Vales
and Corresponding Stereoacutes for Stereoacuity n Seconds ofArc and Shepard
Percentages
Stereoacuity
Test Distance (cm) (seconds of are) Stereoacuity in Seconds of Stereoacuity in Shep-
Are ard Percentages
10 3,090
20 772 1,000 400 200 100 4
30 343 50 16
50 124 40 31
60 86 20 51
80 100 110 130 48 15 72
150 200 300 31 10 78
26 95followlng
Note: Shepard percentages are calculated using the
Note: Response to all eight trgets must
be correct. The stereo-threshold vales 18 formula of Fry57: 100
in this tafole are calculated for an
14 Percentage stereopsis = '^r106 -5
interpupillary distance of 60 mm, The f\
valu (stereoacuty) is calculated using 8 ti+ 81
an x valu of 2,5 mm, which s the 3 where f[ is trie symbol for Stereoacuity.
displacement of one strip from the
plae of the other two strips. Verhoeff stereoacuites are
calculated according to the same formula used for the Howard-
Dolman test (see footnotes to Table 2-27).
parity cells. Hie58 cited a study by Richards59 that
reported that 30% of subjects showed inabilities to
detect disparity, comparing crossed and uncrossed
disparity processing. It was implied that such
distance of 1 m. The better the Stereoacuity, the far-
stereoanomalies are genetic in origin. If lack of
ther away the test apparatus can be held for the
both types of disparity detectors (.e., crossed and
eight correct responses (Tabie 2-28).
uncrossed) are nherited, an individual may lack
normal binocular visin and be at risk for strabis-
Percentage of Stereopsis
mus. Hie58 stated, "It s important in developing
Occasionally, practitioners are asked to report per- and mproving motor fusin ranges." This s partic-
centage vales of stereopsis rather than vales ularly so n small-angle strabismics, who can
recorded in seconds of are. Percentage scales were develop good fusional amplitudes but yet may
empirically determined by Dr. Cari F. Shepard for have a poor prognosis for developing bifixation
such purposes, and calculations and Information (with central, fine stereopsis).
pertaining to this method were presented by Fry.57 In light of this discussion, one may wonder why
Table 2-29 gives percentage vales corresponding random-dot stereo tests, even gross ones, apparently
to Stereoacuity n seconds of are. seem to be effective n detecting sensory binocular
anomalies of suppression, anomalous correspon-
Screening for Binocular dence, and amblyopia. Conversely, the stereo tests
Problems wth Stereopsis with contoured patterns must be within relatively
The level of stereopsis determines the level of bin- sensitive criteria to be effective n this regard. The
ocular status in most cases: Stereopsis s the difference in criteria between the two types of ste-
"barometer" of binocularity, If stereopsis is good, reopsis tests may have something to do with
the binocular status is good, but the opposite can- "local" versus "global" stereopsis. Hofstetter et
not always be said with certainty. That s, a patient al.21 defined local stereopsis as a "very simple dis-
may be found to have no stereopsis but have nor- parity stimulus pattern such as, for example, a ste-
mal sensory and motor fusin n all other respects. reogram with two parallel vertical une segments
Some individuis may lack cortical binocular dis- seen by each eye with slightly differing lateral sep-
64 Chapter 2
I
c
o
o
Q
Ltl
(O
(f) O +1.00 +2.00 +3.00 O +1.00 +2.00 +3.00
o LEVEL OF INDUCED ANISOMETROPIA LEVEL OF INDUCED ANISOMETROPIA O +1.00 +2.00 +3.00
al LEVEL OF INDUCED ANISOMETROPIA
o
NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS 16
i
e
n
o
o
LU
co
05
O +1.00 +2.00 +3.00 O +1.00 +ZOO +3.00 O +1.00 +ZOO +3.00
70" OR BETTER 140" OR SETTER 400" OR BETTE
arations." This same group defined global stereopsis as that global requiring more "visual perception" than does local.
"elicited by the disparity of portions and/ or clusters within It may be that people with poor binocularity have a lack of
relatively large stereogram pat-terns, nvolving complex development n this regard, which might explain why
textured surfaces and repetitive elements for which many they do relatively poorly on random-dot types of stereo
61
disparately paired details might provide ambiguous or tests. A study by Griffin et al. corroborates this con-cept
even conflicting stereopsis clues without destroying the by showing that induced optical anisometro-pia degrades
overlying percept of depth, believed by Julesz to represent global stereopsis more rapidly than local stereopsis (Figure
a perceptual interpretation process dif-ferentiable from local 2-27).
stereopsis."
60
Hamsher confirmed the hypothesis that "the right Norms for Stereoacuity
hemisphere is dominant for global stereopsis but not Rankings of stereoacuity scores are clinically practi-cal for
local stereopsis. The additional mech-anism(s) needed to possible referrals and for assessment of stereopsis before
achieve global stereopsis, while working with and after visin therapy. These rankings are usted in
stereoscopic mechanisms, may not be of a strictly Table 2-30 for contoured (local) and noncontoured
stereoscopic but of a more general visuoperceptive (global) stereopsis. Note that leniency is given for global
nature, perhaps those involved in utilizing subtle cues to stereopsis. These rankings apply to patients at least 7 years
achieve form recognition." od. Pro-
There may indeed be two different types of stereopsis,
Chapter 2 65
fessional judgment s required when evaluating test For example, suppose a patient is found to have
results of children younger than age 7. Because it s asthenopic symptoms when reading, exophoria of
an overall indicator of the patency of binocular 14A, insufficient PRC, and vergence infacility. The
visin, stereoacuity has been used as part of a visin doctor can be reasonably confident that there is
screening test battery. A preschool test that has good fusional vergence dysfunction. It is mportant to
inter-rater test-retest reliability is the Randot Pre- have guidelines, however, as to what is normal and
school Stereoacuity Test.62 This test can be used for what is abnormal for each function. It would be
children as young as 2 years and samples stereoacu- ludicrous for internists who are checking choles-
ity from 800 to 40 seconds of are (see Figure 2-24). terol levis not to know what is considered nor-
mal. Similarly, we have assigned norms to these
visual skills as tentative guidelines for eye care
Summary of practitioners. We believe they are reliable and
Sensory Fusin Testing practical for clinical use. Rankings define n com-
In cases of heterophoria, flat-fusion testing s per- mon terms what is strong or weak, so that each
formed for purposes of measuring binocular visual skill function can be assessed and docu-
accommodative facility, relative vergence ranges, mented before and after visin therapy.
and testing for fixation disparity. Stereopsis gener- Referral to other professionals is indicated if the
al ly s an ndex to binocular status, although some patient's symptoms are not fully abated, despite suc-
patients are stereoblind even though other visual cessful completion of the visin therapy program.
skills may be normal. Ranking of stereoacuity may (Therapy for VSE is covered n Chapter 16.) For
be done in a manner similar to ranking of other example, f the patient has an attention dficit or
visual skills. hyperactivity disorder, medical referral may be ndi-
cated. If a child has Streff syndrome63-64 and contin-
es to experience psychological problems even
RECOMMENDATIONS ON THE after visin dysfunctions are abated, appropriate
BASIS OF TEST RESULTS referral to a mental health professional is indicated.
Similarly, if a patient is found to be dyslexic,65~68
Referral for visin therapy is appropriate if there referral for educational therapy s necessary.
are symptoms of discomfort and performance
problems related to poor visual skills, including
saccades, pursuits, fixation, vergences, and sen-
sory fusin. Referrals should take into account REFERENCES
these considerations and should not be made 1. Revell MJ. Strabismus: A History ofOrthoptic Techniques.
merely because a finding (or even several) s below London: Barrie and Jenkins; 1971:21-22.
average. Professional judgment is necessary when- 2. Policy statement. Pediatras. 1998; 102:1217-1219.
3. Vision, learning and dyslexia. J Am Optom Assoc. 1997;
ever referral decisions are being made. Isolated
68:284-286.
abnormal findings may be spurious. A general pat- 4. Griffin JR, Christenson GN, Wesson MD, Erickson GN.
tern of binocular dysfunction provides the stron- Optometric Management of Reading Dysfunction. Bos
gest basis for making a diagnostic statement. ton: Butterworth-Heinemann; 1997.
chapter 3 / Heterophoria Case Analysis
Most clinical systems used n the analysis of ver- By convention, the graph is plotted with
gence disorders are conceptually based on the accommodative stimulus, in diopters, on the ordi-
interaction of the four Maddox components of nate (y axis) and vergence stimulus, in prism
vergence: tonic, accommodative, fusional, and diopters on the abscissa (x axis). A diagonal line
proximal. Graphical analysis, with roots extend- (Donders' line) is drawn representing conver-
ing from Donders 1 and Maddox 2 in the nine- gence for all points in space along the midsaggital
teenth century, uses a cartesian coordnate plae, with no prism or lens addition. This s also
system to Ilstrate relations between accommo- called the detnand line (Figure 3-1). The exact
dation and vergence. To this day, clinicians may positioning of the demand line on the graph is
find t helpful to draw a graph of phorometry influenced by the interpupillary distance (IPD) of
measurements (i.e., heterophoria, relative ver- the patient but, for standard diagrammatic pur-
gence, and relative accommodation) to visualize poses, the graph is traditionally scaled for an IPD
better the interactions. A graph can readily of 60 mm. In cases of a large IPD (e.g., 70 mm),
reveal various clinical syndromes and alert the the convergence demand for binocular eye align-
clinician to inconsistencies n the data. The ment becomes greater with increasing accommo-
analysis implies relation between accommoda- dative stimuli for nearpoint targets. Conversely,
tive response and vergence eye position, n the convergence demand s less for a small IPD
which changes in accommodation affect ver- (e.g., 50 mm). For fixation distances beyond 20
gence and, conversely, changes in vergence cm, however, the error is small and can be
affect accommodation. ignored for clinical purposes.
70 Chapter 3
9 y s JO
3 ^
87 o X
4JO
65 o J / ^o
43 1 / s
3
21
/ 1
w
.6
v> / s -1.50
/ 1 OJO
/> 4-0.50
/ -.
i
4-1.50
/
20 10 0 10 20 30 40 50 60 70 0 90 100 BASE FIGURE 3-1Craphical llustration
IN Priun tcoU ot 6 m. SASE OUT Farm 1.1 .49
of the demand une (dashed Une).
TONIC CONVERGENCE AND while keeping the target perfectly clear. For small
ACCOMMODATIVE-CONVERGENCE/ children, precise focus can be ensured by asking
ACCOMMODATION RATIO them to identify a small letter or figure as the mea-
surement is taken. Proper dissociation of the eyes and
Tonic vergence position of the eyes s ndicated by relaxation of fusional vergence are necessary to mea-
the farpoint heterophoria measurement. The altr- sure the angle of deviation at near. When fusional
nate cover test at far (6 meters) with corrected vergence is completely inhibited, the near hetero-
ametropia most plus (CAMP) lenses s the standard phoria measurement represents a combination of
method of establishing this position. Unless other- tonic vergence and accommodative convergence
wise specified, this rule of testing with CAMP lenses being stimulated at the near testing distance. There
in place applies to all testing procedures involved in may also be psychic vergence effects that are stimu-
the investigaron of binocular anomalies. lated by testing at a near distance, but these are usu-
In some cases of excessive heterophoria or inter- ally small and essentially ignored during routine
mittent strabismus, prolonged occlusion of an eye s clinical evaluation.
necessary to reveal the full magnitude of the tonic The relation between accommodative conver-
deviation. This is because the effects of fusional ver- gence and accommodation is known as the AC
gence responses do not always immediately or, more commonly, AC/A ra/o. The ratio means
decrease on momentarily covering one eye. that for every diopter of accommodative response,
Measurement of the farpoint heterophoria posi- a certain amount of accommodative convergence
tion through a phoropter can introduce other (dependng on the valu of the AC/A ratio) is
sources of error through psychic and accommoda- brought into play. For instance, f the AC/A is 6A per
tive vergence effects. Nevertheless, phorometry 1.00 diopter (D) of accommodation, a patient who
measurements of heterophoria are usually valuable, accommodates 2.50 D will have an increased con-
because these data are compared with other clin cal vergence of the visual axes of 15A.
data obtained under similar testing conditions.
Nearpoint heterophoria s conventionally mea-
sured at 40 cm in the primary position. It s measured Calculated Accommodative-
with either the altrnate cover test (objectively) or by Convergence/Accommodation Ratio
phorometry (subjectively). During testing, control-
There are several ways to calclate the AC/A ratio
ling the influence of accommodation s extremely
from far and near deviations. The general formula s
mportant. The patient should be instructed to fixate a
detailed nearpoint target requiring precise focus AC/A = IPD (n centimeters) + ([Hn - Hf\/[An -Af\)
Chapter 3 71
TABLE 3- 7. Calculated Accommodative- Convergence/Accommodaton Ratio Depending on Far and Near Mag-
nitudes of the Angle ofDeviaton foran Interpupillary Distance of60 mm
Angle H at Far
Exo Eso
35 30 25 20 15 10 5 0 5 10 15 20 25 30 35
35 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6
30 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4
25 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2
20 28 26 24 22 20 18 16 13 12 10 8 6 4 2 0
1S 26 24 8 6 4 2 00
i 24 22
22
20
20
18
18
16
16
14
14
12
12
10
10 8
6 4 2
z 105 18 16 14 12 10 8 6
e 22 20 4 2 0
01 0 20 18 16 14 12 10 8 6 4 2 0
5
g 5 18 16 14 12 10 8 6 4 2 0
** 10 16 14 12 10 8 6 4 2 0
15 14 12 10 8 6 4 2 0
20 12 10 8 6 4 2 0
25 10 8 6 4 2 0
30 8 6 4 2 0
35 6 4 2 0
Eso = either esophoria or esotropa; ixo = either exophoria or exotropa; H - the objective horizontal angle of deviation of the visual axes.
where An = accommodative demand at near n from 4/1 to 7/1. An AC/A ratio greater than 7/1 is
diopters; Af = accommodative demand at far in high and less than 4/1 is low. If another patient
diopters; Hn = objective angle of deviation at near has 15A exophoria at near as well as at far, the AC/
(A); and Hf= objective angle of deviation at far (A). A ratio s 6/1. Note that the size of the IPD
Note that eso deviations have positive (+) vales, directly affects the magnitude of the calculated
whereas exo deviations have negative (-) vales. AC/A ratio; the larger the IPD, the larger s the AG/
This formula assumes that the CAMP lenses are A ratio.
n place and that the AC/A ratio is linear. Any two Table 3-1 gives the calculated answers for vari-
viewing distances can be used, but they are cus- ous angles of deviations at far and near. Looking at
tomarily 6 m and 40 cm. Flom 3 offered a clinically this table makes two useful rules readily apparent.
useful form of this general formula: First, the AC/A ratio s equal to the patient's IPD
when the deviations at far and near are the same.
AC/A = IPD + M (Hn - Hf)
For nstance, orthophoria (0) on both scales for
where M is the fixation distance at near in meters. In angle H ntersects at 6/1. The AC/A ratio is 6/1 on
this case, the distant fixation (Hf) must be at 6 m or the chart wherever the angles of deviation are
farther. For example, assume that a patient with a 60- equal. Also, a zero AC/A ratio s very improbable,
mm IPD has 15A of exophoria at far and is ortho- and a negative ratio is probably impossible. The
phoric at the near fixation distance of 40 cm. The AC/ table indicates those spurious combinations that
A would be 12A/1 D, which s calculated as follows: could produce either a zero or negative AC/A ratio.
If these questionable combinations occur, the mea-
AC/A = 6 + 0.4(0-= 6
sured magnitudes of deviation for far and near
+ 0.4(15) = 12 (i.
should be rechecked. For example, if the patient
e., 12A/1 D)
has an IPD of 60 mm and a measurement of 0A at
An AC/A ratio of this magnitude s considered far and 15A exo deviation at near, the combination
very high. Normal calculated AC/A ratios range indicates an AC/A ratio of zero, which suggests an
72 Chapter 3
error in clinical testing. However, this deviation of AC/A magnitude, particularly f low-powered lens
0A at far and 15A exo deviation at near s possible if additions are used. The calculation method usually
the IPD is larger. If, for nstance, the IPD s 70 mm, yields a higher valu, because proximal conver-
instead of 60 mm, the AC/A ratio would be 1/1, gence is a factor when fixation s shifted from far to
which is possible. near. Both methods are useful, however. In general,
the calculated AC/A ratio s more reliable than the
gradient method, but the gradient valu may be
Gradient Accommodative- more useful for prognosis, because it directly shows
Convergence/Accommodation the effect of added lenses on the angle of deviation.
Ratio Added lenses often are used in visin therapy to
The magnitude of the AC/A ratio may also be deter- change the magnitude of deviation, n cases of both
mined by measuring the effect of spherical lenses phoria and strabismus. For example, n cases of
on vergence. At far, minus lenses are used for this esotropa, t is often useful to measure the AC/A
purpose; at near, either plus or minus lenses will ratio in children by the gradient method using large
give the valu. Regardless of the testing distance, lens changes such as +3.00 D and -3.00 D to
the AC/A ratio should be determined with the observe the effect of added lenses on the angle of
patient wearing CAMP lenses. strabismus at near.
The following is an example of how the gradient In graphical analysis, the far and near hetero-
method may be used. Assume that a patient has phoria measurements taken through a phoropter
exophoria of 15A at far, as determined by objective are plotted; then a straight line s drawn to con-
means such as the cover test or, possibly, by sub- nect them. This line s called the phoria line. The
jective diplopia testing (e.g., Maddox rod). A AC/A ratio can be determined by direct inspec-
spherical lens of -2.00 D s placed before each tion by noting the change n the deviation per
eye. The patient is nstructed to focus and clear the unit change n accommodative stimulus. The pho-
fixation target while looking through the lenses. ria line is clinically useful because it predicts the
When the patient reports that the target is clear, magnitude of the heterophoria at various testing
another measurement of the angle of deviation is distances (Figure 3-2).
made. If the lenses cause the angle to changefor
example, from 15A exo deviation to 5A exo devia-
tion, the gradient AC/A ratio is 5/1. This s deter-
ZONE OF CLEAR, SINGLE
mined by dividing the change in the deviation by
BINOCULAR VISION
the change of accommodative stimulus (i.e., the
power of the added lenses). Thus, 10 divided by The zone of clear, single binocular visin (ZCSBV) is
2.00equals5 A/1 D. a graphical representaron of the functional relations
Clinically, the gradient AC/A ratio is most often between accommodation and vergence. The ZCSBV
determined at near by using a phoropter. The near- is enclosed by the extremes of accommodation and
point heterophoria s measured subjectively by vergence that can be elicited while maintaining
either the von Craefe method or Maddox rod. clear, binocular fusin. The vertical limits of the zone
Spheres of +1.00 D are added, and the heteropho- are traditionally defined by the absolute amplitude
ria is remeasured. The magnitude change of the of accommodation. (Monocular testing results are
angle bf deviation indicates the gradient. Greater used because of well-established norms.) This
precisin is gained by using +1.00-D, then -1.00- monocular amplitude is determined by the push-up
D added lenses to evalate the amount of devia- accommodation test. At each particular viewing dis-
tion change. If there is a large depth of focus, tance, the horizontal limits of the zone represent the
either +1.00 D or -1.00 D may be an insufficient base-in (Bl) and base-out (BO) blurpoints, usually
stimulus to elicit a sufficient accommodative measured with Risley prisms. Ideal ly, the diver-
response. In such cases, larger increments of lens gence limit s measured before the convergence
power might be required. limit (at each viewing distance), to reduce the
The gradient method will usually give a lower effect of prism adaptation. Relative vergence blur-
AC/A ratio than will the near-far calculation points are indicated by circles. They are plotted for
method. A gradient valu of more than 5/1 is con- at least two viewing distances, customarily at 6 m
sidered high. The depth of focus causes the reduced and 40 cm. At 40 cm, they are designated by circles
Chapter 3 73
/
10 20 30 40
Pri,KaUol6m.
50 M 70 BO
BASE OVT
M MO BASE
Fwm M*4*
for negative relative convergence (NRC), which is Bl blurpoint s reported by the patient, the breakpoint
to blur, and positive relative convergence (PRC), (diplopia) is charted; this s symbolized by a square.
which is BO to blur; at 6 m, they are the Bl to break The blurpoints of negative relative accommodation
(designated by a square, as blur should not normally (NRA) and positive relative accommodation (PRA)
occur) and the BO to blur findings (Figure 3-3). also are designated by circles and often are added
During prism vergence testing, t is customary to to the charting of the ZCSBV (not illustrated n Fig-
record the blurpoint (and the breakpoint and recov- ure 3-3 but shown in Figure 3-5).
ery point) in a particular vergence direction, conver- The zone of single binocular visin can also be
gence or divergence, at each viewing distance. If no plotted (Figure 3-4). This enclosure is formed by
BASE IN frota icol o 40 cm. BASE OUT 35 25
15 5 0 5 15 25 35 45 55 5 75 BS
9.50
O BA D
1
\
1110 MEAK A 8JO
KEOOVEKY X
9t FHOKIA 7JO
J s
76 i / S s-
7
/ s / ^
34
\ /
/ / s
c
SM
32
! / s
s 4JO
1
i
z /
:
/ / 11
8 3M
-"8
/ / /\
/
9
-2JO
I
/ /
/
-UO
y
%
/ ?
(i
/! / ^
/ OJO
v/
\^,
T 4.ACA
r- s* s*
/ / \s / 4.1 ca
/
FIGURE
20
IN
"10 "
y 0
W
10
^, 20 30 40
Pmm KaU o> 6 m.
50 0 70 BO
BASE OUT
0 100 BASE
Farm |.|*-4
12 11 MO
u*.
Q-l tEAJC
10 9 -JO
A-W :covEX
87 xn Y
fOUA
43
/ / i -&50
^ - ?
43 o
i
1 / s SJO
s
\ /
1
I
.
/ s s J
s^\ c
4.50
3JO
^
i / o
I 1 ^
/
........ _ 2 JO
t
o
1
vi
1 V / / ^
^ 1
/l"t~ A /
OJO
r^
f
- J B +OJO
*^/
-^^
21 i ^
s
20
~t J
0 *"" 0
//
/ J" 10 " 20 30 40 SO 0 70 W 0 100 ASE
+1.SO
FIGURE 3-4Zone of single binoc-
ular visin. Vision s diplopic outside
IN
I Prim cok ot < m. ASE OUT Form 1-19-49 the enclosure.
connecting the breakpoints, and t s larger than the 1. The ZCSBV approximates a parallelogram
ZCSBV. The rea difference between these two slanting toward the right, owing to the
zones represents the use of accommodative ver- influence of the AC/A. The AC/A line serves
gence to maintam a single mage (at the expense of as the axis of the zone. If there is a large
clarity). As BO prisms are ntroduced, alignment of deviation from a parallelogram, then spuri-
the eyes s maintained by fusional convergence. ous data points should be suspected, and
Similarly, the accommodative posture of the eyes s retesting s ndicated.
stimulated through the convergence-accommoda- 2. The slope of the zone is influenced by the
tion/convergence (CA/C) reflex. A normal accom- slope of the AC/A. The slope of the zone
modative lag can often become a small lead of often deviates slightly from the demand
accommodation without the patient reporting line. Large deviations, however, probably
accommodative blur, due to the effect of an eye's are associated with binocular anomalies
depth of focus. At some point of increasing prism (e.g., very steep slope ndicating excessive
demand, however, fusional convergence is exhausted; esophoria at near).
the only way a patient can then maintain binocular 3. The vertical limits of the zone represent the
alignment and fusin is to recruit accommodative amplitude of accommodation, which can
convergence. This results in excessive accommoda- be judged as either sufficient or insufficient
tion for the fixation distance. Target blur then s for the patient's work requirements.
reported when the depth of focus is exceeded. As 4. The horizontal limits of the zone represent
BO prism induction s continued, a point is reached the ranges of fusional divergence and con
at which even accommodative vergence is inade- vergence, which can be judged as either
quate. At this point (i.e., the breakpoint), binocular sufficient or insufficient for the patient's
fusin is lost and diplopia s reported (see Figure work requirements.
3-4). 5. The BO blur limit of the zone s steeper (i.e.,
A number of characteristics of the ZCSBV can be fans out) from the Bl to blur line and the pho-
useful in clinical interpretation. A plot of the zone ria line, primarily owing to the influence of
allows the clinician to predict how a patient will proximal (psychic) convergence for nearpoint
respond to various prisms, lenses, and viewing dis- targets but also possibly related to conver
tances. Some of the important attributes of charting gence (prism) adaptation with nearpoint
a ZCSBV are llustrated n Figure 3-3 and are Usted stress and during testing with BO prism
here: demands.
Chapter 3 75
3 /
/
/*
1 : / /
/ C
Ti
-4JO
*
43
/ : / / / f
0
21
a
E / /
: S 9
7IW
-USO
3
AJO
,y>*
+130
(lower circle) and the positive relative / /
accommodation (upper circle).
, /A
i
20
IN
yr
"10 - 0 10 $ 20 30
Pmmttob tm.
40 50 O 70
tASE OUT
0 0
Foon I-19-49
100 BASE
TABLE 3-2. Clinical Norms of Morgan TABLE 3-3. Morgan's Correlations among Selected
CHnical Findings
Acceptable Range
Test Mean 0.5 SO Furvctions
Phora, far 1Aexo 1 Ortho 2* exo
Age and amplitude of accommodation -0.80
iO blur, far Q&
2 ?Ho11A PRA and amplitude of accom modation
TO brk, far 1QA
4 154to23A PRC blur and break +0.80
BQ rec> far 10** 2 84tOl2A NRC blur and break
11 brk, far 7A 2 5H09* NRA and PRC +0.70
Bl rec, far 4* 1 3a to 5a PRA and NRC +0.50
A
Phoria, near 3 ' 3 Ortho to 6 exo NRA and PRA +0.50
BO btur, near 17* 3 W td ZO* +0,50
214 NRA = negative relative accommodation; NRC
iO brk, near 3 18a to 24A -0.50
= negative relative convergence, base-n to blur
IO rc, near 11a 4 7Ato15A atnear; PRA = positive reiative accommodation; PRC = positive
Bl blur, near 13a 2 1Pto15 A relative convergence, base-out to blur at near.
Sitarte, near 21A 2 19a to 23A
Bl rec, near 13A 3 Wtolo^
PRA -2.37 D 0,62 -1.75Dto-3.00 D
NRA +2.00 D 0.25 +1.75Dto+2.25 D
on of the time. The selection of one criterion criteria for evaluating lateral phoria imbalance is Sheard's
over another usually is based on a particular criterion. In 1929, Charles Sheard, a biophysicist at
clinician's training, experiences, and biases. Ohio State University, suggested that the clinically
Several criteria currently in use are reviewed significant relation n assessing vergence dysfunc-tions
here. is the magnitude of heterophoria as compared with the
range of compensatory fusional vergence. He
proposed that the compensating vergence "reserve"
Morgan's Expected Criterion should be at least twice the demand (heterophoria) to be
Morgan's expected ranges for near and far physiologically sufficient.4 Therefore, the PRC should be
hetero-phorias have been used as clinical at least twice the magnitude of an exophoria, and the
vales for the prescription of prism or added NRC should be at least twice the amount of an
lens power. The idea is that f a patient has an esophoria. Sheard's criterion proposes that f the reserve
excessive phoria falling outside the expected is less than this amount, a patient s likely to develop
vales, a prism or spherical lens addition s asthenopic symptoms with sus-tained visual activity
prescribed to compnsate for the phoria. The (e.g., reading a book). If, indeed, a patient does report
lens or prism shifts the demand line rel-ative to visual symptoms and fails to meet Sheard's criterion,
the phoria line, so that the measured phoria then compensating prisms (or a lens addition, in some
then falls within expected limits, as can be cases) can be deter-mined. The goal is to prescribe suff
shown graphically. We will refer to this prism icient prism (or added lens) so the compensating relative
prescription criterion as Morgan's expected vergence would be twice the demand. This can be
criterion. For exam-ple, if a patient reports accom-plished by either inspection of the graph or by
eyestrain while reading and has an exophoria calcu-lation. The formula for calculating Sheard's prism
of 10A at near, the spectacle prescription would s: Sheard A = ([2 x demand] - compensating relative
be 4A Bl to reduce the phoria to 6A exophoria vergence)/3. That is, A = (2D- R)/3.
with respect to the new demand; this s a Two examples are offered to demnstrate the use of
limiting expected valu. Sheard's criterion. If a symptomatic patient has a
Clinical Wisdom Criterion nearpoint exophoria of 9A and PRC ranges of 6/10/4
Another criterion based on the amount of the taken through the phoropter, then analysis would
hetero-phoria is called the clinical wisdom indcate that Sheard's criterion at nearpoint is not met.
criterion. Its ori-gin s obscure, but it seems to The demand is 9Aexophoria, and the PRC (blur-point) s
be passed from one generation of clinicians to 6A. The reserve is much less than twice the demand. The
the next. The criterion vares with the direction PRC in this case should be 18A BO to blur to satisfy
of the deviation. If a patient has visual Sheard's criterion. A prism can be prescribed to meet the
symptoms and poor performance associated theoretcal criterion. Sheard's prism = (2D- K)/3 or ([2 x
with an excessive exophoria, then clinical 9] - 6])/3 = 12/3 = 4A Bl. With 4A Bl in place, the
wisdom would recommend prescribing prism n measured phoria would be reduced from 9A exophoria to
the amount of one-third the angle of deviation to 5A exophoria, and the reserve of 6A would be increased to
bring symptom-atic relief. For example, if the 10A. This prism, therefore, satisfies Sheard's criterion
exophoria measures 12A by cover test, then 4A (i.e., 2D = R, or 2 x 5 = 10). In the spectacle
Bl would be prescribed. The prism amount prescription, the prism would be split, 2A Bl each eye.
would usually be split between the two lenses The patient may expe-rience mproved visual comfort
(.e., 2A Bl each eye), to reduce weight and and efficiency. There is evidence that Sheard's criterion
optical distortion. However, n the cases of eso- s clinically effec-tive, particularly in exophoric cases. 7
phoria and hyperphoria associated with signs A better approach when feasible, n lieu of prism
and symptoms, clinical wisdom would compensa-tion, s to prescribe convergence visin
recommend neu-tralizing the entire angle of training with the goal of building the PRC to at least 18A
deviation with prisms or adds, if appropriate. For BO to blur, which would satisfy Sheard's criterion.
example, if 4A esophoria and 2A right The second example is a far and near esophoric
hyperphoria were found by cover test in a patient reporting visually related headaches at the end
symptomatic patient, the prism prescription of a workday. Phoropter findings indcate a far
would be: oculus dexter 2A BO and 1A base- esophoria of 5A wth 3A farpoint Bl to break and, at near,
down; oculus sinister 2A BO and 1A base- esophora of 7A with an NRC of 5A (to blur). Henee,
up.Sheard's Criterion Sheard's criteron is not met at either far or
One of the oldest and most widely used clinical
78 Chapter 3
near. Chapter 3
near.The Sheard prism atfar would be: A= (2D- R)/ graph. The amount may necessarily be different for
3 = ([10 - 3]/3) = 7/3 = 2 1/3A BO. The Sheard prism near and far viewing.
at near would be: A = (14 - 5)/3 = 3A BO. One Percival's criterion can also be applied by calcula-
approach is to prescribe 3A BO in single-vision tion. A useful formula is: Percival's A = 1/3 L - 2/3 S,
spectacles, as this prism would satisfy Sheard's crite- where L = larger relative vergence range and S =
rion at far and near. However, if the symptoms were smaller relative vergence range. For example, if the
related primanly to nearpoint work, another PRC is 24A (L) and the NRC is 9A (S), the prism neces-
approach could be taken using plus added lenses. sary would be
The Sheard's prism at near, 3A BO, could be satisfied Percival's A = 1/3 L-2/3 S
by prescribing a plus add for near, based on the gra- --= 1/3 (24) - 2/3 (9) =
dient AC/A ratio. If the gradient AC/A ratio measured 8-6 = 2ABO
4A/1 D in this case, then a +0.75-D add would also
balance the relationship between the demand and A visin training approach in this case would cali for
reserve to satisfy Sheard's criterion. (Sheard add = fusional divergence training (also called Bl training}
required Sheard prism/gradient AC/A ratio.) This add to increase the NRC to satisfy Percival's criterion.
combined with the lens correction for any existing FIXATION DISPARITY ANALYSIS
farpoint refractive error might be prescribed in sin-
gle-vision lenses for nearpoint (e.g., reading or com- Besides evaluating the relation between hetero-
puter work). A bifocal prescription could also phoria and vergence ranges, vergence disorders
achieve the desired results if appropriate for the can be identified and managed using the clinical
work needs of the patient. In addition, fusional ndex of fixation disparity.
divergence training should be considered as either Definition and Features
an altrnate clinical approach in such cases or in Fixation disparity is a slight manifest misalignment
combination with optical treatment. of the visual axes (minutes of are) even though there
is single binocular visin with central sensory
fusin. The misalignment can be horizontal, verti-
Percival's Criterion cal, or torsional; however, the magnitude of the
Percival's criterion differs from the other criteria in deviation is within Panum's fusional reas, resulting
that it ignores the phoria position. Percival pro- in a single binocular percept of a target. Ogle9 sug-
posed that the clinically important relationship in gested that the magnitude of the fixation disparity
the ZCSBV is the position of the demand Une with depends on the amount of the innervation to the
respect to the limits of convergence and diver- extraocular muscles during fusin. This innervation
gence blur unes.8 He delineated a zone of comfort is related to the magnitude of heterophoria, the
resting within the middle third of the ZCSBV, lim- strength of compensating fusional vergence, and the
ited horizontally by the blur lines on either side complexity and detall of the visual target.
and extending vertically from O to 3 D of accom- Fixation disparity is not always considered to be
modative stimulus. Percival believed that the abnormal. It may represent an individual's physio-
demand line should ideally fall within or at a limit logic habitual set point from which other binocular
of this comfort zone. If it did not, then prism, disparities are registered (e.g., for stereoscopic
added lens correction, or visin training was indi- depth perception and as a stimulus for vergence eye
cated. The clinician can assess whether Percival's movements). In fact, for fusional vergence error cor-
criterion is satisfied by direct inspection of the
rection, it serves a useful purpose. Schor and
plotted ZCSBV and by adding the NRC and PRC
Ciuffreda10 indicated that fixation disparity may be a
findings and dividing by three. This trisects the
purposeful error signal that provides a stimulus to
total range of fusional vergence and defines the
zone of comfort, the inner third. Does the demand maintain a particular level of vergence innervation.
line fall within the zone of comfort for all viewing Nevertheless, fixation disparity often indicates stress
distances? If not, the amount of prism necessary to on the fusional vergence system and can be associ-
shift the demand line to the nearest limit of the ated with excessive heterophoria, deficient fusional
comfort zone can be easily determined from the vergence compensation, and asthenopic symp-
Chapter 3 79
DEMAND UNE
POLARIZED TARGET
POLARIZED FILTERS
11
toms. Both abnormal and normal aspects of fixa- considered a fixation disparity.
tion 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 resid-
ual fixation disparity that indicates a normal set
point for that individual.
An example of an exo fixation disparity s llus-
trated 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 align-
ment 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 small-
angle strabismus, despite a manifest misalignment
12
of the visual axes. Morgan summed up the quanti-
fication of fixation disparity by stating, "Normally,
fixation disparity rarely exceeds 10 minutes of are,
although it may be somewhat greater when a sub-
stantial 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 approxi-
mately the magnitude (0.9) of a prism diopter, it is
A
practica! to consider any manifest deviation of 1 or
greater as being a strabismus. If the deviation s less
A
than 1 and there is foveal fusin, the condition s
Clinical evidence suggests that excessive fixa-
tion disparity tends to reduce stereopsis. Col and
13
Boisvert 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
14
another study, Levin and Sultn neutralized
existing fixation disparities in 12 subjects by
means of prisms to determine the effect on stere-
oacuity 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 com-
mon 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 mea-
sure of fixation disparity (e.g., Saladin Card [Figure
3-7]) and the Wesson Card (Figure 3-8). The Sala-
din Near Point Balance Card allows for both disso-
ciated and associated phoria measurements. The
numbers 20 exophoria to 20 esophoria are for hor-
izontal phoria testing with the modified Thorington
method using a Maddox rod; the 10-10 scale s for
vertical measurements. The associated phoria, hor-
izontal or vertical, can be measured using the two
80 Chapter 3
RJU.
iva
ADTS
Mons
NOdTI ATd
anos
A '" M "~" X ~"~ A ~~ Z
SnHn Eq. LogMAR
e7
i HZDiV -
RtHyper
80 RKCOS O-6
t 63 ZSDNG O.S
v c o i HI Hypo
YEMA
8 50 0EKVR 0.4
*
40 C D N K H 0.3
. ZH v ns 0.2
32
25 ..... 0.1
SLOW
*4 20 0.0
'2 18 0.1
S A C
1B 1R 1d 19 1O R K A O = > /i e e A lo 4A -IB 1O O
UTO
THEN
UPON
K J I H G F E 2X C B A
18X 14X 10X 8X 6X 4X 18 2S 4S
S8t SH SOI- ss 9 S* 2 XV X*
4
Z A X AA A i y
E
n
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 Aialsts E1
3. FD and phoria should be in the sane direction . Assume O tneaswement error 2.
given 2' of FD measurement error VeoicaFDshouWbeiessthan l'of
4. Noticeable variability for either FD or phoria is gfe and in the same direction as the
abnonnal vertieal phoria
64
Chapter 3 81
Red
FIGURE 3-8Representation of the Wesson Card for fixation disparity (F.D.) testing.
targets n the upper left-hand crner, in which a phoria are the Bernell test (Figure 3-9) and the Vec-
foveal fusin lock appears n each center (see Fig- tographic Slide (Figure 3-10) or similarly designed
ure 3-7). The other circles are without a foveal targets. Vertical associated phoria can be measured
fusin lock and are used for targets to plot a fixa- with either test; the Bernell test can be rotated 90
tion disparity curve (FDC; discussed later). Exam- degrees to test for vertical fixation disparity (see
ples of those tests that indcate only an associated Figure 3-9b).
DISPARITY
b. u
c. o 9-
O ame
m E ui
E a u E
d.O h. O n
-e
oo oo o oo oo o
oo oo o oo oo o
oo oo o oo oo o
oo oo o oo oo o A
FIGURE 3-10Results of fixation disparity testing with the Vectographic Slide. a. No fixation disparity. b. Eso fixation disparity (oculu s dexter
[OD] dominant eye). c. Eso fixation disparity (mixed dominance). d. Exo fixation disparity (OD dominant). e. No vertical f ixation disparity.
f. Hyper fixation disparity (OD dominant). g. Incyclo fixation disparity (OD dominant). h. Foveal suppression of oculus sinis ter (OS), i. Adult ver-
sin of the Vectographic Slide. (Courtesy of Stereo Optical Co.) j. Children's versin of the Vectographic Slide. (Courtesy Stereo Optical Co.)
The associated phoria is the minimum amount having the patient focus on the reading portion of
of prism that is necessary to neutralize a fixation the test and then look at the central target when t
disparity. Theoretically, this is the X intercept (XIN, is lluminated. The vernier perception at that
pronounced "zin"). For example, an exo fixation moment is used for clinical purposes. The pris-
disparity would be neutralized with Bl prisms (Fig- matic power that produces alignment for the
ure 3-11). Knowing the direction of fixation dispar- patient is the XIN measurement.
ity and the amount of prism required to reduce it to Fixation disparity targets similar to the vecto-
zero (measurement of the associated phoria) are of graphic slide (see Figure 3-10) are good for deter-
clinical importance. The XIN (associated phoria) mining the farpoint-associated phoria. The patient
should not be confused with the magnitude of the wears crossed polarizing viewers and is instructed
fixation disparity, theoretically the Yntercept (YIN, to keep fixation on the center of the bull's-eye tar-
and pronounced as such). The XIN is measured by get and to report any noticeable misalignment of
Chapter 3 83
DIPLOPIA
BASE-IN BASE-OUT
DEMAND DEMAND(A)
24
DISSOCIATED PHORIA
OF 8A EXO
BLUR
o
15
15 *!
^~ ^-
10
DISSOCIATED PHORIA OF 5
8A EXO ^^^^
BASE-IN . . V
DEMAND ' ' "/"N.
24 18 12 /6 \ 6 12 18 24
ance Card.
11
the vertical or horizontal Unes. If there is no mis- test. The Mallett Unit is held by the patient at the
alignment, the clinician can conclude that there is preferred working distance and position as when
foveal fusin with no fixation disparity. If there s reading. The centrally fused target s an X. Two verti-
misalignment, compensating prisms are used to cal bars (one above and one below the binocularly
crate vernier alignment. The power of the neutral- seen X) are covered with mutually exclusive polar-
izing prism is not the magnitude of the fixation dis- izing filters. One line s seen only by the right eye
parity (YIN) but, rather, the measurement of the and the other only by the left eye. As in farpoint test-
associated phoria (XIN). ing, any horizontal associated phoria (XIN) should
A good example of target design for nearpoint fix- be measured using the mnimum amount of neutral-
ation disparity testing s the Mallett fixation disparity izng prism. The fixation target s flashed for each
84 Chapter 3
measurement, and the patient is instructed to look The FDC is plotted by measuring the magnitude of
mmediately from the reading material to the X. fixation disparity that corresponds with varying
(Some clinicians prefer to have the patient continu- amounts of Bl and BO prism. Risley prism increments
ally fixate the X.) Any vertical associated phoria of 3A are advised to produce clinically useful curves.
should also be measured, using a target at another Fixation disparity is measured initially with an ortho
location for that purpose. demand. Subsequent measurements are taken in the
An associated phoria measuring 1A or more may following orden 3A Bl, 3A BO, 6A Bl, 6A BO, and so
be clinically significant if accompanied by hetero- on. The limit of forced vergence in each direction is
phoria and deficient fusional vergence ranges, partic- indicated when a prism results in either diplopia of
ularly if the patient reports asthenopic symptoms. In the target or suppression of one fiducial. The instru-
contrast, an associated phoria independent of symp- ment is designed for measurement of both horizontal
toms or other signs may be clinically insignificant. and vertical fixation disparity.
Generally, the direction of the fixation disparity is The Wesson Fixation Disparity Card (see Figure
consistent with the direction of the dissociated het- 3-8) is a relatively inexpensive device but less pre-
erophoria (e.g., eso fixation disparity often occurs cise than the Disparometer. It can be hand-held or
with esophoria). However, as Ogle9 showed in his attached to a phoropter nearpoint rod; it also
classic studies of fixation disparity, the two occasion- yields an approximate FDC. One study indicated
ally occur in opposite directions (e.g., an exophoric that curves taken with the Wesson Card and Dispa-
patient might exhibit an eso fixation disparity). In rometer correlated highly if esophoric and exo-
such cases, the direction of the fixation disparity is phoric subjects were analyzed separately.17
considered to be the more important clinical indica- Figure 3-11a illustrates an FDC of a patient with
tor of the underlying oculomotor stress pattern. In normal binocular visin, whereas Figure 3-11b
such a case, BO prism may possibly be prescribed to shows an FDC of a patient with vergence dysfunc-
neutralize the eso fixation disparity, even though the tion reporting asthenopic symptoms. Note the fol-
patient has an exophoria (under dissociated testing lowing clinically relevant features of the abnormal
conditions). Vision therapy to improve motor fusin curve: (1) the significant fixation disparity at the
ranges is, however, usually preferred in such cases ortho demand position; (2) the relatively large asso-
over prism prescription. ciated phoria (XIN); (3) the steep slope (exceeding
It is sometimes advisable to plot a fixation dispar- 45 degrees) of the curve at the ortho demand posi-
ity-forced vergence curve, clinically called the fixa- tion; and (4) the limited range of fusional vergence.
tion disparity curve. The Sheedy Disparometer was These features of the curve confirm the presence of
the first clinical instrument commercially available a vergence dysfunction. Another feature of the FDC
for this purpose.15 This instrument has a series of that has been suggested to be indicative of a ver-
preset vernier lines that allows direct measurement gence dysfunction is variability of the amount of fix-
of the fixation disparity magnitude (YIN). The Dispa- ation disparity and the curve over time (i.e., large
rometer can be attached to the nearpoint rod of a day-to-day variation). In individuis having normal
phoropter at the 40-cm viewing distance, although binocular visin, the FDC appears to be quite stable
t can also be hand-held by the patient with nearly or reliable over time within a limited range of forced
the same accuracy.16 Crossed polarizing filters are convergence and forced divergence.18
used to clue the fiducials to the right and left eyes. The Saladin Near Point Balance Card allows for
Fixation disparity is measured by the examiner dial- measurement of angle F (YIN) as well as the associ-
ing in the particular vernier lines for the patient's ated phoria (XIN). Testing is more convenient than
perception of exact alignment. The horizontal fixa- with the Disparometer, because dialing of each pre-
tion disparity magnitude (YIN) can be determined to set vernier displacement is unnecessary, as they are
an accuracy of 2 minutes of are, using the bracket- all exposed.The horizontal array measures eso devi-
ing (method of adjustment) technique. The patient is ations or exo deviations, and the ranges can be
asked to focus on the letters adjacent to the circular extended for each direction by rotating the card 180
target containing the vernier lines. The vernier lines degrees; similar features apply to the vertical array
are transilluminated with a penlight by means of (hyper or hypo deviations) measurements, for which
fiberoptic tubes. The examiner illuminates the lines ranges also can be extended by rotating the card.
intermittently, and the patient is instructed to look Four basic types of FDCs were described by Ogle
from the letters to the illuminated vernier lines and et al.9 and are believed to have differential diagnostic
report any misalignment of a line and its direction. valu (Figure 3-12). The type I curve has a sigmoid
Chapter 3 85
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.
ra criterion." Sheedy's criterion for the prescription clinical measurement are found with Instruments
of prism is based on nspection of the FDC. If the similar to the Mallett Unit, Bernell Unit, and Saladin
curve is steep where it crosses the YIN (ortho Card with ortho demand target for near testing or
demand position) and the patient has fusional prob- the Vectographic Slide for far testing. These targets
lems and symptoms, Sheedy recommends prescrib- contain central fusin contours. We believe a cen-
ing the least amount of prism that places the ortho tral fusin lock is necessary when the associated
demand position on the flattest portion of the curve. phoria criterion is used for the prescription of prism.
If, for example, the FDC s steep at the ortho The associated phoria is determined by adding
A
demand position but flattens out at the 4 BO loca- prisms until neutralization occurs. The patient
A
tion of the x axis, the prescription would be 4 BO should be instructed to determine whether vernier
prism. This would shift the ortho demand position to alignment is achieved with each prism power
the flattest segment of the FDC, f there s no prism within a time limit of 20 seconds after the prism has
adaptation. If there is no completely fat portion, been ntroduced. Beyond this time, there may be
Sheedy would recommend prescribing sufficient significant prism adaptation to invaldate the mea-
10
prism to place the patient's ortho demand on the surement of the associated phoria.
flattest portion of the curve. We believe, however, VALIDITY OF DIAGNOSTIC GRITERA
that visin training s of great valun such cases, to
Validity and reliability of diagnostic criteria need
flatten the curve near the ortho position.
to be established before the clinician can securely
The associated phoria criterion s the least
apply them to patient management. However,
amount of prism that neutralizes the fixation dispar-
ity (XIN). Typically, the targets used to make this
88 Chapter 3
most of the diagnostic criteria used in the prescrip- this problem are discussed: (1) a comparison of
tion of prism and lens additions n cases of ver- subjective and objective vergence measurements
gence dysfunction have not been subjected to and analysis, (2) clinical criteria that discrimnate
rigorous tests of concurrent validity; their use has subjects with and without binocular symptoms,
evolved slowly by experience n clinical practice. and (3) prism prescription clinical triis.
A measure of face validity accrues to the criteria of Grisham25 objectively recorded the dynamics of
Sheard, Percival, Sheedy, and associated phoria, vergence eye movements n two groups of sub-
because they are al I based on notions that have jects. One group had clinically determined ver-
physiologic credibility, but much of the evidence gence dysfunctions and asthenopic symptoms and
supporting their clinical use is anecdotal. the other had normal binocular visin. An auto-
Craphical case analysis can be criticized on the mated vergence stimulus was presented on a mod-
basis of the subjective methods used in clinical ified haploscope, and an infrared eye monitor was
testing of accommodation and vergence through a used to record the vergence responses. Vergence
phoropter. Phorias, relative accommodation, and latency, velocity, and tracking rate were objectively
vergence endpoints can be influenced by a num- determined variables that discriminated between
ber of nonphysiologic factors, including a patient's the two clinical groups. Grisham reported accept-
(1) understanding of the instructions, (2) attention able concurrent validity between the clinical and
level, (3) cooperation level, and (4) conscious objective analyses of these subject groups and
effort expended. In addition, (5) rate and smooth- demonstrated that the objective analysis estab-
ness of prism or lens power induction by the exam- lished the same categories of differential diagnosis
iner, (6) elapsed time between tests, and (7) the as did a clinical analysis of vergence and hetero-
amount of central and peripheral contour n the phoria characteristics.
fixation target affect these parameters. The way that Sheedy and Saladin26 also evaluated the validity of
instructions are phrased also can make a signifi- case analysis diagnostic criteria; however, they used
cant difference in the measurement of vergences: the statistical technique of stepwise discriminant anal-
For example, "Report when the image splits into ysis to rank the effectiveness of many commonly used
two" may elicit a quite different response than clinical criteria in differentiating symptomatic from
might "Try to keep the image single, but report asymptomatic nonstrabismic subjects. The symptom-
when it doubles."23 With several nherent sources atic subjects all had clinically determined hetero-
of nonphysiologic variation and error, how can the phoric and vergence disorders. Phorias, vergences,
examiner trust the validity and reliability of these and FDCs were measured on all subjects. Sheard's cri-
clinical methods? More important, can any crite- terion proved to be the best single discriminant vari-
rion for distinguishing a disorder from normal able for the entire population, particularly for the
functioning, based on these endpoint measure- subgroup of exophoric subjects. For esophoric sub-
ments, be considered valid and reliable? Fortu- jects, however, the magnitude of the deviation (pho-
nately, these questions can be answered, at least ria) was the most discriminating factor (Table 3-4).
for clinical purpose. The power of these individual variables in success-
Morgan23 found that tests for the farpoint phoria fully discriminating between the two subject groups
showed high reliability even when the interval (90% correct) supports the overall validity of binocu-
between tests was many years. Most standard clin- lar visin case analysis as an effective clinical
ical tests of far and near heterophoria have accept- approach.
able reliability and concurrent validity, with the One direct approach for assessing the use of a
exception of the Maddox rod test at nearpoint. 24 particular clinical criterion for the prescription of
The reliability may be mproved, as Saladin sug- prism is to allow the patient to choose between two
gested,24 by having the patient hold or touch the comparable spectacle prescriptions, one including
penlight to stabilize accommodation at the 40-cm the particular prism amount and the other similar in
test distance. However, little has been reported on all respects except for the prism. Worrell et al.27
the test-retest reliability of Risley prism vergence were the first to use this technique when they
ranges. assessed the prism prescribed by Sheard's criterion
There is evidence to support the overall validity in 43 subjects with oculomotor imbalance and
of graphical analysis and other clinical criteria of asthenopic symptoms. They found that the Sheard
vergence assessment. Three different approaches to prism was accepted at a statistically significant level
Chapter 3 89
for measuring the curve35 and gives consistent XIN from being excessive, but t allows the clini-
Information whether the device is mounted before cally significan! fixation disparity component due
a phoropter or s hand-held.16 Sheedy's criterion to fusional vergence stress to be revealed. Fortu-
for the prescription of prism can be applied, there- nately, the Saladin Card provides a target with a
fore, with some assurance of a reliable and valid foveal fusin lock for measuring the associated
method of evaluation. We recommend using the phoria (XIN). In other words, the foveal fusin lock
Disparometer, Saladin Card, or Wesson Card as an might elimnate the appearance of the physiologic
adjunct diagnostic procedure in cases of suspected fixation disparity, but t allows the clinically signifi-
vergence dysfunction when applying Sheedy's cri- cant fixation disparity component due to fusional
terion for the prescription of prism. The Saladin vergence stress to be revealed.
Card is based on the targets used in the Disparom-
eter, and we presume its effectiveness is compara-
ble. Further research is needed for confirmation.
RECOMMENDATIONS FOR
Dowley36 has concluded, however, that the
PRISM PRESCRIPTION
associated phoria measured with a Disparometer
(and, by implication, the Wesson Card), s not as Other than the studies by Sheedy and Saladin,26 lit-
reliable as the Mallett Unit. The Disparometer has tle research has been conducted to compare the
a fusin stimulus, an annulus that s 1.5 degrees in relative effectiveness of the various criteria for pre-
diameter, but no centered foveal binocular stimu- scribing prisms and adds to alleviate vergence dys-
lus, which the Mallett Unit does have. Studies have functions. In the absence of abundant research
demonstrated that the FDC s less variable and the data, clinicians adopt treatment preferences based
associated phoria has a smaller magnitude if the on their own clinical experiences. From our expe-
target contains a foveal fusin stimulus.37'38 Agree- riences, we make the following recommendations
ing with Dowley, we recommend that clinicians regarding the relative effectiveness of prism pre-
use a Mallett Unit, a Bernell polarized nearpoint scription criteria (Table 3-5). Our initial bias in
testing unit, or the Saladin Card to measure associ- most cases of significant heterophoria, or ntermit-
ated phoria if prisms or adds are to be prescribed tent strabismus, is to recommend visin training for
by the associated phoria criterion. Our experience improvement of fusional vergences. Prism com-
indicates that associated phoria prisms identified pensation may also be necessary as a supplement
by the Disparometer are often excessive and to training. When visin training is an unaccept-
rejected by patients. By contrast, the Mallett Unit able alternative or training results are unsuccessful,
prism amount usually is accepted by patients and prism therapy becomes the treatment of choice.
proves to be beneficia! if there are asthenopic The clinical wisdom criterion for prism prescrip-
symptoms and other signs of a vergence dysfunc- tion works well for exophores, esophores, and
tion. The foveal fusin lock prevents the measured hyperphores at both far and near. Generally speak-
Clinical vwisdom 3 3 3
Sheard's crterton 3 3 NA
Perdyal's criterion 1 2 NA
Associated phoria 3 3 3
Ftatportion @f fixation disparity curve 2 2 NA
{iheed^'s eriterion)
Pfismconfirmtri pro eedur 3 3 3
Prlsmsptation test 1 1 1
3 ^ tHartjTSN"! faoA 1 ''= Imf, NA = not applicable.
Chapter 3 91
ing, exophores require less prism than esophores, foveal and peripheral fusin stimuli, such as are
angles of deviation being equal, due to the greater found on the Bernell slide, Mallett Unit, and the Sal-
relative strength of fusional convergence. Prescrib- adin Card. When a series of prism amounts is found
ing a compensating prism that is one-third the angle to neutralize the fixation disparity, the minimum
of deviation is often appropriate for exophoria, up amount s prescribed with good effect; asthenopic
to a deviation of 30 A . The prism can be split symptoms usual ly are ameliorated and the patient
between the eyes and usually does not present a adapts well to the prism spectacles. Care must be
serious probiem (i.e., optical distortion, weight, or taken, however, when prescribing a prism for one
cosmesis) f the eye size (spectacle dimensin) is distance to ensure that a fixation disparity is not
kept small. In cases of symptomatic esophoria and induced at another distance. For example, Bl prism
hyperphoria, clinical wisdom calis for a prism equal may neutralize a fixation disparity at 40 cm for
to the angle of deviation as measured by the cover reading but induce a large eso fixation disparity and
test. However, in cases of relatively great magni- associated phoria for viewing televisin at 3 m with
tudes, this criterion becomes impractical due to that same prism. In this case, the prism spectacles
optical considerations. Lesser amounts of prism may be unacceptable and rejected for general wear
should be applied and evaluated empirically. but suffice for sustained nearpoint activity. There-
The studies of Sheedy and Saladin26 and Worrell fore, testing of associated phoria should be done at
et al.27 generally support the use of Sheard's crite- both far and near to judge the effect of a particular
rion and conform to our clinical experience. We prism amount. Sometimes, prism spectacles
have found t useful in both esophoria and exo- should be given for a specific viewing distance.
phoria patients but not in hyperphoric patients. It This management principie is applicable to pre-
seems to be particularly valuable in cases of symp- scribing prism by any criterion, but the associated
tomatic presbyopic exophoria, a class of patients phoria is a convenient criterion, because the prism
who often are neglected clinically. amount can easily be assessed by testing with far
Percival's criterion is used less frequently than and near targets.
Sheard's criterion in clinical practice, although Diagnosis of a binocular visin dysfunction
Sheedy and Saladin26 found it may have validity in rarely s made on the basis of a single test; like-
many esophoria cases. wise, a prism seldom is prescribed unless a num-
Prism prescribed by the associated phoria crite- ber of criteria indcate the necessity for \\The
rion has been shown to be accepted by symptom- amount of prism power recommended by ech cri-
atic esophoric and exophoric patients in clinical terion often vares, and the clnician must use pro-
studies,27'28 but it is mportant that the test target fessonal judgment. When there is coherence
have both central and peripheral fusin contours. among cnteria, the decisin s relative easy, but
Sheedy's criterion (i.e., the fat portion of the when there s wide varation, the validity of each
FDC) has clinical utility, although we generally use criterion should be questioned. Often, retesting or
t when the other cnteria are inconsistent or they additional testing s required. Particularly n these
indcate unreasonable prismatic prescriptions. This situations, a prism confirmation procedure should
criterion lacks popularity largely because measure- be carried out.
ment and plotting of the FDC s time-consuming. We recommend the following procedure to test
Clinicians often work around this time-demanding the suitability of any particular prism: Many
obstacle by visualizing the FDC based on fairly patients with an oculomotor imbalance will imme-
routine findings (i.e., dissociated phoria, associ- diately experience some relief of their symptoms
ated phoria, and fusional vergence ranges). (See when a compensating prism of appropriate magni-
the discussion on visualizing the FDC n the sec- tude is ntroduced. If an esophoric patient's symp-
tion Fixation Disparity Analysis.) toms are related to reading, for example, a reading
We have had good experience using the associ- test card is given to the patient to view. Let us
ated phoria criterion (i.e., the minimum prism that assume that the associated phoria criterion indi-
neutralizes the fixation disparity) for the prescription cates 4A BO, so a lose prism of this amount would
of prism in esophoria, exophoria, and hyperphoria be used n the confirmation test. With the prism n
cases, although some clinicians disagree.39-40 The place, the patient s asked whether the print
prism amount we prescribe s derived from clinical appears to be clearer or whether visin s more
testing on fixation disparity targets having both comfortable than without the prism. The prism
92 Chapter 3
power that neutralizes a fixation disparity will usu- spectacle lens. This is best performed after the
ally make print appear closer.41 A valid prism pre- membrane and lens are washed and still wet. (Also
scription is ndicated when there is a strong see Chapter 11, under Optical Therapy, for discus-
acceptance response by the patient. To check for a sion and llustration.)
placebo effect, however, the prism direction is
reversed surreptitiously and again tried. Validity is
confirmed if there is strong rejection of the
VERGENCE ANOMALIES
reversed prism. If, however, the patient accepts the
reversed prism, further triis with different prisms The predominant classification system for ver-
are necessary. If no prism is accepted by this con- gence disorders is based on the tonic deviation of
firmation procedure, the prescription of prism is the eyes and the AC/A ratio. It is used to describe
often unwarranted. Other approaches to resolving both strabismic and heterophoric cases and is
the patient's problem might be recommended widely accepted in optometry and ophthalmology
(e.g., visin training, lens power additions, chang- and by interested third-parties (e.g., insurance
ing viewing conditions, or referral for a general companies). Duane42 first proposed this model of
health examination). classification, which clinically is called the Duane-
If, after applying these prism-prescribing meth- White classification. Schapero43 also used this
ods, a question still remains regarding whether a model as a basis for his 10 case types. Duane pro-
prism is appropriate, a prism adaptation test may be posed that a difference of at least 10A between the
helpful in resolving the issue. Heterophoric patients far and near deviations was necessary before a
having normal binocular visin with no ocular patient should be classified into one of his four
symptoms typically show strong prism adaptation. original categories. Other writers have suggested a
After wearing a prism for approximately 10 minutes, 15A difference between far and near, and many cli-
they often will have the same, or nearly the same, nicians use 5A. We prefer to use a 5A difference or
phoria as originally measured. For example, if a 6A greater between the deviations at far (6 m) and
exophoric patient with normal binocular visin near (40 cm) to indcate the presence of an abnor-
wears a 6A Bl prism (which initially neutralizes the mally high or low AC/A ratio.
angle of deviation) for a short period, the examiner The larger vales typically are used by oph-
typically finds the phoria to be increasing, resulting thalmic surgeons, as the desired level of accuracy
in another 4A to 6A of exo deviation. The prism in surgical procedures is approximately 10A. Com-
would be ineffective, because that patient reverts to pensation of the angles of deviation with prisms
the habitual phoria through the spectacles. Con- and added lenses, however, is more refined and
versely, symptomatic patients with vergence prob- often the therapy of choice. For example, if a
lems usually benefit from prism compensation and symptomatic patient with an IPD of 60 mm mani-
do not typically show significant prism adaptation. fests orthophoria at far and 10A esophoria at near,
If a prism, worn for 10 minutes, contines to neu- the calculated AC/A ratio is 10A/1 D. This conver-
tralize the angle of deviation, then that prism estab- gence excess often is treated with a bifocal add,
lishes an acceptable physiologic relation between using the effect of the high AC/A ratio to reduce the
the heterophoria and the compensating vergence, near deviation. However, if the same symptomatic
relieving the oculomotor stress. Complete prism patient measured ortho at far and 5A esophoria at
adaptation, when it occurs, usually is complete near, the calculated AC/A ratio would be 8 A/1 D,
within 24 hours, but most of the adaptation occurs which is considered to be high by Morgan's nor-
within the first 10 minutes. This test is, therefore, a mative data. Added lenses at near remain an ideal
relatively quick clinical procedure. The results of management approach. We believe a 5A difference
this test are not always clear-cut, and interpretation between near and far deviations is consistent with
often is difficult. At times, this can be a good backup optical treatment approaches, and so we prefer
test of prism acceptance, but professional judgment this amount for the sake of clinical categories of
remains necessary. vergence anomalies. This assumes that there are
Applying Fresnel prisms to spectacle lenses can symptoms and visin inefficiencies resulting from
also be used for prism adaptation testing and, the vergence anomalies. Implicit in any of the
occasionally, for permanent wear. The smooth side Duane-White categories is poor compensatory
of the membrane is placed on the ocular side of a fusional vergences.
Chapter 3 93
_
For example, with prolonged occlusion, a nearpoint
S
S 7 BLUR O / / ,' deviation of 3A exophoria may increase to 10A exo-
Z A
RECOVCRY
PHORIA X / ( / /
phoria. If the far exo deviation is 10A, the correct
/ diagnostic category would be basic exophoria. A
Q / \/ ' /
1 e
' s spasm of fusiona! convergence at near is one possi-
^
y
f ble explanation for a spurious result from the initial
o* / ' f ' /
S3 J S s .^ c^ cover test. Prolonged occlusion is necessary for
0 convergence to decrease sufficiently to reveal the
5 /^ s r'"
01 /
2
y / ' / full magnitude of the exo deviation at near. There-
y
fore, these apparent cases of divergence excess are
<1 - -f
0
^Xc/
)
0
'
D 0 0 0 called s/mu/aed divergence excess, also known as
0 1
3
(C ONV 3 2 4 5 pseudo-divergence excess.
E RGE 2E ( In the case of true divergence excess, which
N
A indeed has a high AC/A ratio, the patient may experi-
ence esophoric problems at very near viewing dis-
FIGURE 3-15Basic exophoria representad graphically.
tances (see Figure 3-16). If fusin is maintained most
of the time at far and the AC/A ratio is not extremely
gence can easily be expanded, visin training for high, divergence excess patients often respond well
exophoria (and intermittent exotropia) is effective to visin training, but they are not generally as suc-
in tnese cases. Bl prism is also effective in manag- cessful as patients with other types of exo deviations.
ing basic exophoria if there is little prism adapta- In some cases, a minus add prescribed overall helps
tion, because it reduces the convergence demand the patient to control the far deviation, acting through
equally at all distances, and the amount of needed the high AC/A ratio, but the amount of overminus
prism usually is not excessive. must be carefully considered so as not to induce an
esophoric problem at near. Bl prisms, too, may be
useful, but there remains the same reservation about
Divergente Excess inducing an esophoria at near. Many clinicians rec-
Divergence excess exophoria is indicated when a ommend plus-add bifocals along with visin training
significantly large exo deviation at far is combined in the management of divergence excess cases (see
with a high AC/A ratio. If a patient presents with Chapter 14).
10A exophoria at far and 3A exophoria at near and,
after a prolonged occlusion test of 10 minutes, the
deviations do not significantly change, then diver- Divergence Insufficiency
gence excess is indicated (Figure 3-16). Divergence insufficiency esophoria is the least
Some patients presenting with divergence excess prevalent of the esophoria cases. It is defined as a
actually nave s/mu/ated (pseudo) divergence excess. 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
BUO
/
(,/' poor. For them, driving a vehicle, particularly at
ACCOMMODATION (D)
BMUK Q
RECOVeilY
&PHORIA X
/ /y ' s night, can be a serious problem.
/^ Successful management of some cases of diver-
/ f ' s
S ^S
/ s gence insufficiency is difficult. One approach that
3-<>s>U<tkUiO-S09
S / s*~
t
seems moderately effective is to prescribe BO prism
y ^ correction in single-vision lenses for general wear.
* ^
------- ------- -------
/
-
^ A
~
^ ^ For example, this may be 8A BO if the far esophoria
'
-X
X-
S / ^ is 12A. If there is no prism adaptation, the resulting
-2O "-IO o" 1O
^ _^
Jf**r
20
^ 3O 4O SO farpoint esophoria would be 4A, which considerably
CONVERGENCE (A) reduces the fusiona! divergence demand. However,
with these spectacles in place, the near eso devia-
tion would measure 5A exophoria instead of 3A eso-
FIGURE 3-16Divergence excess represented graphically.
Chapter 3 95
8
BLUR O BRf
27 / 1
ts
AK Q
RECOVEflY A BLUR O
,f
ACCOMMODATION (D)
PHORIA X ! 1 BREAK Q / y
RECOVERY A
s: / /
PHOHIA X
1 S'/
1 1 / / / ,'
/ S
/
4
o J ' / ',' / /
1
3->N>UklnO>NCD
0 / / /
9
fi
~Y
sL
/ f^
/
-j
~Y
/,
3 ^ - -
u '
1 s - */ -S 7>-
/
^' J /s 10" J
^
/.'
Y/
/
//
-20 -10 "O 20" 30 4O 50 n
-20 -10 "0 *s ^20 3O 40 50
CONVERGENCE (A) ^
CONVERGENCE (A)
RGURE 3-17Divergence insufficiency represented graphically. FIGURE 3-18Basic esophoria represented graphically.
phoria. This amount s not excessive by Morgan's report experiencing nearpoint problems because
norms, but caution is needed in that an nduced exo the esophoria increases dramatically as the view-
deviation at near s not compatible with the esopho- ing distance becomes closer. Eyestrain, blurring,
ria at far. A visin training goal to necease diver- and ntermittent diplopia often are reported. These
gence ranges would be preferable, but sometimes patients are vulnerable to developing an accom -
BO prism s required to maintain comfortable fusin modative esotropa. Associated findings include
fbr sustained viewing at far distances. (Therapy for low NRC, low PRA, high NRA and, possibly,
divergence insufficiency is discussed in Chapter 13.) esotropa at very near fixation distances. Latent
hyperopia also s frequently associated with con-
Basic Esophoria vergence excess; therefore, cycloplegic refraction
is advisable n most cases of convergence excess.
Bas/c esophor/a is characterized by a significant eso
Usually the full hyperopic refractive error must be
deviation at far and a modrate AC/A ratio, so that
corrected f it measures +1.00 D or more. Because
the far and near angles of deviation are approxi-
of the high AC/A ratio, plus-add bifocals usually
mately equal. An example would be esophoria of
are indicated for reading and other nearpoint
1P at all viewing distances (Figure 3-18). Other
activities. The amount of the add should be deter-
associated findings often include reduced NRC, a
mined empirically by measuring with the cover
low PRA, and high NRA. BO prism s an obvious
test and listening to subjective reports of improve-
and safe treatment approach in basic esophoria and
ment of visin and comfort. BO prism may also be
usually is effective, because most symptomatic eso-
phores do not adapt to prisms. Vision training s also
useful in combination with prism prescription.
Without the prism, completion of divergence train- BLUM O
SCOMMODATION (D)
S' ^/-. ^- ^
1
Convergence Excess ^ r^
< ^ ^
Convergence excess esophoria is the case that typ- -2O -1O "( ^
id" 2O 30 40 50
cally presents with little or no esophoria at far but CONVERGENCE (A)
with a high AC/A ratio. An example would be
A
orthophoria at far and 7 esophoria at near (Figure
3-19). Patients with convergence excess often FIGURE 3-19Convergence excess represented graphically.
96 Chapter 3
MODATION (D)
/; ' / /
BLUR O
ACCOMMODATION (D) 3-
BHEAK O
HECOVERV A
i* * Wi 0> S 09 | PHORIA X
/
/
/
^
BLJUR
BdtAK
O
O
/ / S
'
y// RECOVEflT A
/
PHOBIA X J /
,'
/S J S / /
//.
ty / /
<iouuio>Nea
/ / ,
S /
5 & / /,
*
O
0 2
y' -^ <^f s'
^f
V'' rV
0 J
^ / ^ '
/'
-20
CONVERGENCE (A)
-1O ""$"10 2O 3O 40 5O
' X
-20 ^ 0 O" 20 30 40 SO
CONVERGENCE (A)
FIGURE 3-20Restricted zone representad graphically. FIGURE 3-21Symptomatic patient with normal zone of clear,
single, binocular visin represented graphically.
necessary if there s a significant eso deviation at If the condition proves to be caused by accom-
far. Vision training is recommended to break any modative and vergence dysfunctions, visin train-
suppression and to expand the range and facility of ing is recommended. This mode of visin therapy
fusional divergence. Frequent progress checks after is usually successful within a matter of a few
training usually are indicated, as regression may weeks. The visin training goal would be to
occur in the absence of an active home mainte- expand the range of the entire ZCSBV and
nance program of visin training. improve the facility of all oculomotor functions.
Sst
Chapter 3 97
dentified (e.g., general health problems, drug One of the most useful research tools of bioengi-
reactions, or psychological distress). Sometimes neers is to build mathematic control models of bio-
diagnostic visin therapy can be undertaken to logical systems and then to compare them with
determine whether symptoms decrease. If the final empiric physiologic evidence. The model s modi-
conclusin s that the symptoms are not of binocu- fied until ts features accurately simlate physio-
lar origin, a referral for a medical or psychological logic responses and are consistent with what s
evaluation s n the best interest of the patient. known aboutthe anatomy of the biological system.
Several mportant insights have evolved from the
relation between control systems modeling and
physiologic evidence.
BIOENGINEERING MODEL The accommodative system of the eyes and the
Maddox48 believed that the vergence system could vergence system are cross-linked and dynamically
be categorized by four additive components tonic, influence each another. Accommodation drives
accommodative, proximal (psychic), and fusional convergence (AC/A) and convergence drives
(disparity) vergence. Graphical analysis based on accommodation (CA/C). When both systems are
this concept was developed gradual ly by several stimulated simultaneously, the cross-links interact
notable individuis such as Percival, Sheard, Mor- and respond differently from when either system is
gan, Fry, and Hofstetter and became the scientific stimulated n isolation.49 Classic graphical analysis
bundation for binocular case analysis. We have has not taken into account this dynamic relation-
emphasized the graphical analysis perspective in ship and has largely gnored the influence of the
this chapter and adapted the Duane-White classifi- CA/C. Nevertheless, clinicians have long been
cation scheme to heterophoric disorders. We also aware that disorders of accommodation and ver-
applied Morgan's normative analysis, which s con- gence often are associated.
sistent with classic graphical analysis. In Chapter 2, Stimulation of some adaptive mechanisms for
the emphasis was on evaluating various oculomotor the AC/A, CA/C, and fusional vergence result in
systems over time, testing the dynamic components tonic changes n both accommodation and ver-
of each system. Accuracy, speed, and stamina were gence. Therefore, there are both momentary and
distinctive clinical features n that analysis. These more lasting adaptations to prism and lens stimuli;
two perspectives, graphical analysis and visin effi- a particular patient's physiologic responses to
skteA toes os ^'ms cm^te 3m\u\aty \K&-
each delinales visual functions, and disorders dicted in all conditions of clinical management.
thereof, that the other may neglect. For example, Schor50 suggested that the lack of vergence adapta-
disorders of accommodation, other trian accommo- tion s an mportant, if not the most mportant,
dative insufficiency, are ignored by classic graphical characteristic of patients having vergence disor-
analysis. Vision efficiency analysis of accommoda- ders. Clinical observations that are consistent with
tion, however, includes evaluation of lag of accom- this viewpoint include the finding that a steep FDC
modation (accuracy), facility (speed), and stamina s one indicator of resistance to "good" vergence
(sustainability). adaptation and that good vergence adaptation may
Originating in the 1950s, fixation disparity anal- increase when visin training s successfully com-
ysis tended to reinforce and supplement the ver- pleted.51 In other words, prism adaptation does
gence evaluation of graphical analysis. Graphical increase and the FDC tenas to flatten with train-
analysis and fixation disparity analysis emphasized ing.52 What we mean by "good" vergence adapta-
different aspects of vergence and accommodative tion must be distinguished from "bad" prism
dynamics, but the systems were intimately related, adaptation, which normally takes place n symp-
as they both described the same underlying oculo- tom-free individuis with normal binocularity n
motor physiology. What has become clear since which a compensating prism will be "eaten up."
the time of Maddox s that vergence and accom- For this reason, prisms are considered poison for
modative physiology, and disorders thereof, are compensaron unless they are absolutely neces-
substantially more complex than Maddox origi- sary. A prism should not be prescribed n cases of
nally formulated. This realization has largely come heterophoria unless there are symptoms (associ-
to light through a bioengineering systems control ated with vergence dysfunction) that can be
approach used in basic research. relieved by lessening the vergence demand with
98 Chapter 3
^ +
Desired
Accommodative . Accommodative
Level Response
Desired ""
Vergence
Level
Vergence
^ Response
Ciliary
+ Blur
Detectors
Accommodative
Controller
Slow
Adaptation
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 adapta- (e.g., fixation disparity testing). Wick and London54
tion relates to visin training n which increased suggested that an improved graphical analysis
prism demand (rather than compensating prism) s approach would result from plotting and evaluat-
introduced for the purpose of increasing fusional ing a graph of the associated gradient AC/A ratio
vergence ability and, ultimately, favorably affecting (derived from FDCs), the proximal vergence ratio,
tonic vergence. and far and near FDCs. Such an approach may
The influence of proximal vergence on near- indeed prove to be a significant mprovement over
point vergence eye position has been largely traditional methods, but ts incorporation into a
ignorad n classic case analysis, yet in some practica! clinical examination probably awaits
patients the amount of proximal vergence can sig- technologic advances that would allow oculomo-
nificantly influence the associated phoria status, tor measurements to be easily taken and tran-
for better or worse.53 Wick and London54 proposed a scribed directly nto a computer program for
versin of the Hung-Semmelow model of nter- analysis.
actions between accommodation and vergence We have drawn our concept of a very simplified
that takes into account the influence of proximal hypothetical model (Figure 3-22)modified from
convergence. They emphasized that one difficulty other bioengineering models, particularly that of
with the traditional system of binocular case analy- Saladin56to Ilstrate the possible interaction
sis is that the vergence deviation that exists under between accommodation and vergence and the
binocular (associated) conditions often s not the ways in which responses may be affected by the
same as that measured under dissociated viewing nteraction between accommodative convergence
conditions (e.g., Maddox rod test). They joined and convergence accommodation as well as feed-
Saladin55 in a strong appeal for evaluating binocu- back nformation, accommodative and vergence
larity under closed-loop (associated) conditions adaptations, and proximal convergence.
Chapter 3 99
TABLE 4-1. General Guidelines for Characteristics That Might Differentiate between Essental Infantile
and Later-Acquired Esotropa
Altrnating devation (often a midline switch) Unilateral deviation (in majority of cases)
Possible lack of any correspondence {often unable to prove Presence of correspoodence (either normal or
any correspondence wtth testing) anomalous)
Often no awareness of diplopta (only altrnate perceptfon of Diplopc awareness possible (true simultaneous
images) pereeption)
Double hyper deviation and often excyclorotation of covered No double hyper deviation (dissociated vertical deva--
eye (dissociated vertical deviation in majority of eases) tion possible but rare)
Insignificant refractive errors (occurring occasionally but as a Sgnifcant refractive errors (e,g., hyperopia causing
seprate component of the strabismus) accommodative esotropa)
Normal or low AC/A ratio (may be high, but usually normal) High AC/A rato (e.g., hgh ratio causing nearpoint
accommodative esotropa)
Little or no functional ambiyopia (alternating fixaton pre- Unilateral functional ambiyopia (constant unilateral
venting unilateral ambiyopia) strabismus causing ambiyopia)
AC/A = accommodative-convergence/accommodation.
tuted. An eso deviation of comparable magnitude, receive sympathy, or for other reasons designed to
however, often begins as a constant strabismus. gain something from others.
Whether the deviation was alternating or unilat- In the event that a patient has not been exam-
eral at the time of onset s an important fact to ined previously by another ophthalmologist or
establish, especially in the evaluation of ambiyo- optometrist and reports of the patient's refractive,
pia. An alternating strabismus is less likely to cause visual acuity, and binocular status are unavailable,
ambiyopia than is strabismus that s unilateral. The the practitioner must depend largely on the
onset of ambiyopia, therefore, cannot be equated patient's or parents' statements for any history. A
with the onset of alternating strabismus; a history good Une of questioning directed to parents of
of unilateral strabismus is more definitive n regard young patients is the following: "When the turning
to time of onset of ambiyopia. of the eye was first noticed, did the eye turn out
Reports of noticeable variations of the strabis- toward the ear or n toward the nose? Was it
mus angle may be useful. Changes of magnitude in always the same eye that turned, or did the other
different positions of gaze suggest an acquired eye turn some of the time? Was the turning more
paresis as the probable cause of strabismus. If, noticeable at different times of the day? Was t
however, the angle in the primary position is more noticeable when the child looked up, down,
reported to vary from time to time, the deviation to the left or right?" Answers to these questions
may be comitant and due to physical illness, emo- may indcate the mode of onset of strabismus.
tional disturbances, or other causes affecting the
tonic angle of convergence. For example, psy-
chogenic strabismus (either eso or exo) s a possi- Duration of Strabismus
bility, although psychogenic esotropas are much The duration of time elapsng between the onset of
more frequent than are psychogenic exotropias. a manifest deviation and therapy is a crucial factor
The conceivable way that an individual could n the re-education and recovery or further develop-
experience a psychogenic exotropia is by letting ment of normal binocular visin. This s particularly
go of fusin to allow the latent deviation to lapse so in the child younger than 6 years. We believe the
into an exotropia. This usually occurs in individu- best surgical results n infantile esotropa, as indi-
is who use this condition to get their way, to cated by long-term random-dot stereopsis, occur
104 Chapter 4
JABLE 4-3. Typcal Questions in Patent History TABLE 4-4. Objective Testing Procedures for
Jfcgarc/fng Time and Mode of Strabismus Onset Detection of Strabismus in Ascending Order
of Sensitivity
O.D. O.S.
a.
b.
c.
8
with results by the altrnate cover test. 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 measure-
9
ments can be made. This method may be applica-
ble in infants and small children in whom other
methods are not providing consistent results.
d.
Krimsky Test
The Krimsky test has slightly more sensitivity than
the Hirschberg test, yet t is similar, with one excep-
tion: Prisms are used to reposition the corneal light
reflex of the deviating eye to the same relative loca-
tion as the reflex on the fixating eye. The magnitude
of the prism necessary to accomplish this is the
e.
measurement of the angle of strabismus. A con-
founding factor n the Krimsky test s the possibility
of prism adaptation. Therefore, the testing time must
be brief, 2-3 seconds at most. For this reason and
because the Krimsky test is more complicated and
less natural for the patient, we routinely use the
FIGURE 4-2Interpretation of the Hirschberg test n five examples.
Hirschberg test rather than the Krimsky test.
a. Bifoveal fixation, O angle kappa. b. Oculus sinister (O.S.) fixating,
O angle kappa, and 22A esotropa of oculus dexter (O.D.). c. OS fixat-
ing, +1-mm angle kappa, and 22 A esotropa of OD. d. OS fixatng, Unilateral Cover Test
+1-mm angle kappa, and 44A esotropa of OD. e. OS fixating, -1-mm The unilateral cover test s also known as the
angle kappa, and 22A esotropa of OD.
cover-uncover test. Its main purpose s to detect
strabismus by distinguishing it from heterophoria.
best a clinician can expect, because a displacement For example, assume a patient has an esophoria,
of less than 0.25 mm s almost mpossible to discern.
The accuracy of a Hirschberg estmate tends to and the cover is placed before the patient's right
decrease with the size of the strabismic deviation, eye. The left eye would continu to fixate, but the
even among experienced clinicians. The amplitude right eye would move in a nasal direction behind
of large esotropas and exotropias are most often
underestimated by the Hirschberg test as compared the occluder (Figure 4-3). W hen the occluder s
108 Chapter 4
FIGURE 4-4Esotropa of the right eye. (f = fovea; H = magnitude of of dissociation, making fusin impossible. The altr-
the horizontal angle of strabismus.) nate cover test cannot determine whether a deviation
s concealed by fusin.
The test is performed by alternately occluding one
removed from the right eye, the eye would move n
eye and then the other while watching for any conj-
a temporal direction for resumption of bifixation.
gate movement of the eyes, which would indcate a
Similarly, when the occluder is placed before the
deviation. The greater the conjgate movement, the
left eye, that eye would move inwardly behind the
greater is the deviation (either strabismic or phoric).
cover and, when the cover s removed, the left eye
An exo deviation will result n conjgate movement n
would move outwardly in the case of esophoria.
the same direction as the movement of the occluder
An esotropa of the right eye is illustrated n Fig-
("with" motion), whereas an eso deviation causes an
ure 4-4. If the cover is placed before the right eye,
"against" motion during the altrnate cover test.
there will be no movement of either eye because
The testing procedure is best explained by using
only the left eye is fixating. When the cover s
an example. Assume that the patient in this exam-
placed before the left eye, however, the right eye
ple has an esotropa of the right eye of 25A. The frst
will have to move outwardly to fixate the target.
step is to occlude the eyes alternately at a rate of
Also, the left eye will make an inward movement
1-2 seconds per occlusion to determine whether
and be in an eso posture behind the occluder (Fig-
there is an eso, exo, or hyper deviation. The direc-
ure 4-5). The movement of the uncovered eye s
tion and magnitude of the conjgate movement of
the distinguishing feature of strabismus on the uni-
the eyes indcate the drecton and magnitude of
lateral cover test.
the deviaton.
Assuming the unilateral cover test was done pre-
Altrnate Cover Test viously, certain information about the deviation of
The altrnate cover test is also referred to as the the visual axes s already known (.e., whether the
Duane cover test. It may be used with prisms to mea- deviation is strabismic or phoric, the dominant eye
sure the angle of deviation of either a strabismus or preferred for fixation, the direction and estimated
phoria. Although t s a very sensitive method for magnitude of the deviation). Bearing in mind the
detecting a deviation of the visual axes, a limitation knowledge gained from the unilateral cover test, the
of the altrnate cover test s that t cannot differentiate examiner's next step is to occlude the nondominant
between heterotropia and heterophoria (i.e., strabis- deviating eye. In this example, the right eye s
mus versus phoria) as can the unilateral cover test. occluded and no movement of either eye is
This s because, during the procedure, only one eye expected, because the left eye remains the fixating
s fixating at any given moment; the eyes are in a state eye and is motionless. When, however, the occluder
Chapter 4 109
FIGURE 4-7Preparing for the four base-out prism test in the case of
FIGURE 4-6Occluder is switched to the left eye. In this example, no
eye movement is seen because the base-out prismatic power is equal a small esotropa of the right eye.
to the magnitude of the strabismic deviation (i.e., neutralization of the
conjgate movement on the altrnate cover test), (f = fovea.)
A
small esotropic angles, less than 4 , 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
A
the full 4 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
FIGURE 4-10Orthophoric posture of the eyes in the pri primary posi- FIGURE 4-11Orthophoric posture on dextroversion. (f =
tion of gaze. (f = fovea.) fovea.]
To Ilstrate a noncomitant deviation, Figure 4-13 when the nondominant eye is used for fixation. For
shows the eyes in a nonorthophoric posture with this reason, we prefer to restrict the use of the terms
dextroversion: The left eye made a nasal move- primary and secondary deviations to the question of
ment (adduction) larger than the temporal move- comitancy rather than comminglmg the issue of
ment (abduction) of the right eye. Assuming that dominancy (as discussed later in this chapter).
the left eye is the fixating eye, this results n an The secondary angle of deviation is almost
esotropic deviation of the right eye n rightward always significantly larger than the primary angle,
gaze. This same deviation is clinically depicted in according to Hering's law of equal innervation.
Figure 4-14. This indication of noncomitancy is Figures 4-1 6 and 4-1 7 are examples of paresis of
even more evident when Hirschberg testing is the right lateral rectus muscle. The excessive inner-
used (Figure 4-15). vation nvolved in contracting the right lateral rec-
tus s carried over to the yoke muscle, the left
Primary and Secondary medial rectus. The left eye is turned inward to an
Deviations excessive degree, thus causing the eso deviation to
Measurements of the primary and secondary devi- be larger when the paretic eye is fixating.
ations are customarily made n the straight-ahead Differences between the primary and secondary
gaze (primary position) using the altrnate cover deviations may be due to noncomitancies caused
test with prisms, usually at far (6 m), although the by circumstances other than paresis. A faulty mus-
test may also be conducted at near (e.g., 40 cm). cle insertion may test positive in this regard. How-
The magnitude of one angle s compared with the ever, the difference between primary and secondary
magnitude of the other. If a patient has a paretic angles usually is less remarkable than when a
muscle in only one eye, the primary angle of devi- paretic muscle is nvolved. The disparity is usually
ation is the angle measured when the nonparetic greater in the case of a newly acquired paresis
eye fixates, whereas the secondary angle s the than n one of long duration. (There s a tendency
angle measured when the paretic eye fixates. for a noncomitant deviation of very long duration
The literature too often obfuscates the true mean- to evolve toward comitancy, but not to become
ing of the secondary angle by implying that it is the completely comitant, in almost all cases.)
angle measured when the nondominant eye (or the If there is a difference greater than 5A between
deviating eye n strabismus) is fixating. This can be the primary and secondary angles, noncomitancy
misleading, as the nondominant eye may possibly should be suspected. Although a lack of difference
be the nonparetic eye and the dominant eye the would indcate comitancy, there may be excep-
paretic one. Under such circumstances, the primary tions. Mild noncomitancies not caused by nerve
angle of deviation would be the one measured mpairment are often overlooked, as they may not
Chapter 4 113
FIGURE 4-12The nine diagnostic positions (a-i) of gaze for conjgate eye movements, with secondary and tertiary positions indicated.
produce a significant difference in the deviations. positiva findings tend to be true indications of non-
Even some paretic muscles with nerve impairment comitancy.
etiology may show a false-negative finding (i.e.,
appear normal) when they are of long duration. Ductions
Conversely, a false-positive finding of noncomi- The words duction and vergence have caused con-
tancy (the appearance of abnormality when, in fusin n clnica! usage. Technically, ductions are
fact, none exists) sometimes occurs in cases of monocular eye movements (Table 4-7). The com-
uncorrected refractive errors. For example, a patient mon interchanging of the two terms probably arse
fixating with the right eye that s plano may be from clinicians' misuse of the word ductions when
orthophoric, but the patient may have an eso devi- vergences was meant.
ation when fixating with the left eye that s 2.00- Duction testing is useful when evaluating non-
diopter (2.00-D) hyperopic. In general, however, comitancy. It is not as sensitive, however, as versin
O.D. O.S.
Classifcation Vergences
Convergente
Ductions Divergence
Horizontal Adduction
Positive
(nasal)
Abduction (tem-
Negative
poral) Supraduction
Vertical* (elevation) Infraduction
Incyclovergence
P (depression)
a Torsional Incycloduction
r Excyclovergence
(intorsion) Excycloduction
etic
RLR (extorsin)
Dextrosupraduc-
Tertiary tion Levosupraduc-
FIGURE 4-16Esotropa of the right eye n a case of paresis of the postions tion Dextroinfraduc-
right lateral rectus muscle (RLR). The nonparetic eye s fixating a dis-
tion Levonfraduc-
tant target, revealing the primary angle of deviation. (f = fovea.)
tion
*Vertical vergence s also known as vertical divergence. It is posi-
testing, but ductions can be very informative f the tive f the right eye elvales and negativa if the left eye elevates.
extraocular muscles are tested n their diagnostic
action fields (DAFs) (Table 4-8). Each DAF s evalu-
ated by having the patient look in the appropriate
direction, which may be either a voluntary saccadic
eye movement or a following pursuit to the gaze
Another useful differential diagnostic procedure large excursin, complicating the diagnosis of non-
is the forced duction test. This procedure requires comitancy. Dextroversion testing, however, would
local anesthesia of the bulbar conjunctiva and a probably detect the restriction in the DAF of the right
sterile frceps. A cotton-tipped applicator stick s lateral rectus in this case, because an eso deviation
soaked in a local anesthetic such as proparacaine would increase dramaticaliy on rightward gaze.
hydrochloride (Ophthaine) 0.5% and then is The three objective methods of versin testing,
pressed firmly to the bulbar conjunctiva at the I i tri- ranging from least to most sensitive, are (1) direct
bus in the direction of the observad restriction. The observation, (2) Hirschberg testing, and (3) the
conjunctiva is gripped with the frceps at the point altrnate cover test with prism. Each method may
of anesthesia, and the eye s slowly moved n the be used n the nine DAFs liustrated in Figure 4-12.
direction of gaze limitation. Mechanical restric- For example, with dextroversion, the DAFs are for
tions such as contracture or space-taking lesions the right lateral rectus and the left medial rectus. If
can be detectad by the sensation of physical resis- the right lateral rectus muscle s paretic, esotropa
tance. In cases of extraocular muscle (EOM) pare- is likely on rightward gaze, whereas f the left
sis, the eye will move to the extreme position. medial rectus is paretic, exotropia is likely.
To help verify a paresis, the doctor holds the
patient's eye n the primary position as the patient s
asked to make a voluntary saccadic movement n the Three-Step Method
DAF (right gaze n the example given earlier of right Ordinarily, analyzing the eight cyclovertical muscles
lateral rectus paresis). If no pulling (tugging) is felt by s more difficult than analyzing the four horizontally
the doctor, paresis is assumed. However, if a tugging acting recti. A useful paradigm for identifying an
is felt and the forced duction is restricted on passive isolated paretic cyclovertical muscle, taking into
rotation, a mechanical restriction s indicated. 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.
Versions The three-step method is best explained by using
Versions are conjgate movements of both eyes. Test- as an example a known paretic muscle and then pro-
ing for noncomitancy is more sensitive with versions ceeding to the three differentially diagnostic steps.
than with ductions, because a change n the devia- Suppose the patient has a paretic right superior
tion of the visual axes from one position of gaze to oblique muscle. This muscle's main action s infra-
another can be measured fairly precisely in versin duction and, secondarily, intorsion. In the primary
testing, in contrast to duction testing, in which only position, the superior oblique has a slight action of
one eye s being examined and a restriction or over- abduction, but this can be considered negligible for
action must be relatively large to be observed. purposes of our discussion. When the patient fixates
Detecting a change in deviation under binocular see- n the primary position of gaze, the right eye is likely.
ing conditions during versions is relatively easy. For to have a small degree of hyper deviation. This could
example, assume the patient has a mild paresis of the be either hypertropia or hyperphoria, depending on
right lateral rectus muscle. On duction testing, the the results of the unilateral cover test. The likelihood
patient may be able to abduct the right eye with a that a right hyper deviation will be present s attribut-
116 Chapter 4
TABLE 4-9. The Three-Step Method for Identifying a Paretic Cyclovertical Muscle
able to weakened depressing (infraduction) action of and BD prism. The same procedure is performed in
the paretic superior oblique muscle. The magnitude left gaze. If the hyper deviation of the right eye
of the right hyper deviation may be estimated objec- increases in left gaze, the paretic muscles are nar-
tively, either by direct observation or with the unilat- rowed to two possibilities, right superior oblique
eral cover test. For the exact measure of magnitude, and left superior rectus, because both of these mus-
the altrnate cover test with a base-down (BD) prism cles have an isolated vertical action in left gaze.
placed in front of the right eye is used. Theoretically, the right superior oblique becomes
The first column of Table 4-9 lists hyper devia- a pur depressor only when the right eye is
tions of either the right or left eye. The fourth col- adducted 51 degrees, and the left superior rectus a
umn lists the affected muscles from among the pur elevator only when the left eye is abducted
eight cyclovertical muscles. When there is a right 23 degrees (see Chapter 1). For clinical purposes,
hyper deviation in the case of an isolated paretic however, 30 degrees for each lateral gaze is a sat-
muscle, any of three muscles besides the right isfactory and workable compromise. When the
superior oblique may be the cause. They are the possibilities are narrowed to two muscles, the
left inferior oblique, the right inferior rectus, and Bielschowsky head-tilt test is necessary (Figure 4-
the left superior rectus. A paretic left inferior 18). The patient is instructed to tilt the head
oblique could cause a hyper deviation (of the right approximately 40 degrees toward the right shoul-
eye) because its yoke muscle, the right superior der. The same instructions then are given for head
rectus, receives excessive innervation (Hering's tilt to the left shoulder. An increase in an existing
law). In addition, the left inferior oblique is an ele- hyper deviation is the important observation.
vator, and the weakened muscle would cause the Usually, the up-shooting of the hyper deviated
left eye to have a hypo deviation (relative right eye is obvious on right head tilt in this example of
hyper deviation). The same reasoning applies to a right superior oblique paresis. If fusin is strong
paretic left superior rectus, as its yoke muscle, the and the vertical deviation remains latent, the
right inferior oblique, would receive excessive altrnate cover test must be used to dissociate the
innervation to cause a right hyper deviation. Simi- eyes and assess the hyper deviation. A subjective
lar explanations can be supplied for each muscle measurement of the hyper deviation can be mis-
when using the three-step method. leading, because the tilting itself produces a
The number of possibilities can be narrowed "hyper" eye, which should not be confused with a
from four to two by having the patient fixate in two true hyper deviation that can be seen objectively.
lateral positions of gaze approximately 30 degrees Because of this artifact, subjective testing is unre-
each way. In right gaze, the amount of the hyper liable; the examiner must make such an assess-
deviation is measured with the altrnate cover test ment by objective means. Objective assessment
Chapter4 117
RSR
Lateral Gazes: Hyper increases on left qaze Hyper increases on left qaze
RSR
c LIO JLSRj) RSR RIO
c LIO
LSO
Ti
LIR
C RIR RSO) LSO LIR
LIO
LI
RIO)
FIGURE 4-21Analysis of an isolated left superior oblique (LSO) paresis using FIGURE 4-22Analysis of an isolated right superior rectus (RSR) paresis using
oval-like demarcations. (LE hyper = left-eye hyper deviation; LIO = left inferior oval-like demarcations. (LE hyper = left-eye hyper deviation; LIO = left inferior
oblique; LIR = left inferior rectus; LSR = left superior rectus; RIO = right inferior oblique; LIR = left inferior rectus; LSO = left superior oblique; LSR = left
oblique; RIR = right inferior rectus; RSO = right superior oblique; RSR = right superior rectus; RIO = right inferior oblique; RIR = right inferior rectus; RSO =
superior rectus.) right superior oblique.)
the current oculomotor status. If the examination indicates a significant iner so the eyes move to the extreme position n up,
change n refractiva error, spectacles are prescribed, and the patient is down, left, and right fields of gaze. The deviation at
sched-uled for an additional examination after she or he has adapted to the each horizontal or vertical position s neutralized with
lenses. prisms and recorded on a diagram, as llustrated in
Figure 4-23. If neces-sary, the primary deviation is
Step 1: Without correcting for head posture, measured again and recorded on the diagram, without
the presenting deviations at far and near are allowing the patient to assume the habitual head posture.
measured with a prism bar or lose prisms Step 3: The patient's head is rotated to extreme tilted
and are recorded. positions, right and left, and any result-ing hyper
Step 2: While the patient holds fixation with deviation is measured. The results of the head-tilt test
the dominant eye on a distant target (e.g., 6 are simply recorded cise tothe diagram
m), the patient's head is rotated by the exam-
120 Chapter 4
I
OD Fixating OS Fixating
Step 4: The patient s instructed to follow a for grading overactions is illustrated n Figure
penlight, or a toy target, as t s moved nto 4-25 n an example of an overacting right infe-
eight extreme DAFs. The examiner qualita- rior oblique muscle.
tively grades on a ranking scale any observed
overaction or restriction n each field of gaze, In cases of paretic strabismus, overaction of the
as llustrated in Figure 4-24. Restrictions are yoked muscle (contralateral synergist) usually s
graded and recorded on the diagram n the seen. However, in cases of developmental comitant
affected field of gaze. An advantage of this strabismus of long standing, particularly esotropa,
method of recording (as compared with the overactions of the oblique muscles often occur also.
Hess-Lancaster test, for example) is the direct
and easy visualzation of the affected fields of
gaze and comitancy pattern. A similar method
-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 FIGURE 4-25Example of grading of overaction of the right inferior
Jampol-sky, with -1 being the oblique muscle. In this example, the left eye is fixating a target n
most mild and -4 being the extreme left gaze. a. Right eye s approximately 1 mm higher than left
most marked in severity. eye. b. Right eye is approximately 2 mm higher than left eye. c. Right
eye is approximately 3 mm higher than left eye, part of pupil is
obscured by upper eyelid, and right eye is slightly diverging (arrow
represents upward and outward movement of the eye, as well as
extorsin), d. Right eye is nearly 4 mm higher than left eye, most of
pupil is obscured by the upper eyelid, and right eye may be markedly
diverging.
Chapter 4 121
Overactions can present either unilaterally or bilat- to be normal. Correctional judgments of localiza-
erally. Thorough diagnosis requires the grading of tion are learned over time, which explains why sen-
overactions on a 4-point scale. The clinician moves sitivity of this test diminishes in cases of paresis of
the fixation target, often a penlight, to direct the long duration.
patient's fixation into an extreme field of gaze. For If testing is conducted correctly n a newly
example, when checking for an overaction of the acquired case of a paretic right superior oblique mus-
right inferior oblique muscle, the clinician should cle, the patient will likely miss the target by pointing
direct the patient to fixate with the left eye in extreme to the left of the target (.e., patient's left) and below t.
left gaze (see Figure 4-25). Also, testing should be All 12 extraocular muscles can be tested in this man-
performed with the patient's left eye in extreme upper ner, in the DAF of each. Clear-cut evidence of spatial
left gaze. (Likewise, to check for overaction of the localization error implicates a newly acquired paresis
right superior oblique muscle, the fixating left eye as the cause of noncomitancy.
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
Signs and Symptoms
following convention: If the nonfixating eye is 1 Noncomitancy may or may not cause noticeable
mm higher than the fixating eye in up-gaze or 1 problems or be reported. For many young children,
mm lower than the fixating eye n down-gaze, the the deviations must be obvious before their parents
overaction is graded as +1; f the difference s 2 are prompted to pursue examination of such chil-
mm, then the grade s +2; f a 3-mm difference, dren by an eye care professional. Subjective com-
then +3; and f a 4-mm or greater difference, then plaints arising from noncomitancy are relatively
+4. Divergence often accompanies overactions of infrequent in children younger than 7 years. The
the oblique muscles n grades +3 and +4, as s indi- situation s most often that of the parent noticing
cated in Figure 4-25. In the primary position of signs of intermittent deviation rather than the child
gaze, the oblique muscles have the tertiary action reporting diplopia. Likewise, other subjectively
of adduction. On extreme abduction, the eye does reported symptoms, such as nausea and vrtigo,
not move to 51 degrees, where there would be are believed to be more frequent in adults.
purely vertical action, but falls short, allowing for
some abduction. In extreme overactions of the Diplopia
oblique muscles, the abduction becomes apparent. Young children nfrequently report diplopia. We
have seen many children who, when examined
and asked, replied, "I thought everybody sees dou-
Spatial Localization Testing ble." Their lack of life experience and difficulty in
Ritients who have a newly acquired paresis usually articulating what is and what should be may
have spatial local ization errors, as evidenced by explain n part why reports of diplopia may not be
pointing beyond the target's DAF location (clinically heard from many young children who are strabis-
referred to as past pointing). For example, assume mic. Another reason is that young children can
that the right superior oblique muscle is paretic. This usually suppress the aggravating image caused by
muscle should be tested n its DAF (levoinfraduc- the deviating eye.
tion). For such testing, the left eye s occluded. Then, Suppression s more difficult to achieve with
with the right eye fixating, the patient is instructed maturity. Most adults have trouble coping with
to look at a penlight (or any suitable target) located diplopia that results from a manifest deviation of
in the DAF position (to the patient's left and down) sudden onset, such as from a newly acquired
and to touch it with an ndex finger (i.e., pointing). paretic muscle. In such cases, diplopia is the main
Although testing distance s not critical, approxi- reason for an office visit. If, however, a patient has
mately 40 cm s recommended. The patient s told always had poor binocular visin with deep sup-
to move a hand quickly from behind the shoulder pression, diplopia may not be noticed and would
(out of view) to touch the light. This must be done not be a warning of a newly acquired paresis.
rapidly; otherwise, judgment corrections may be
made and the patient will touch the target accu- Abnormal Head Posture
rately (although slowly). Unless the procedure s An affected extraocular muscle can often be iden-
performed correctly, local ization may falsely appear tified merely by observation of the head posture of
122 Chapter 4
TABLE 4-10. Abnormal Head Posture (Position of careful analysis, as with the Hess-Lancaster method
Face) Related to Affected Extraocular Muse/es (discussed later in this chapter). Unlike past point-
ing, the mere passage of time does not tend to
compnsate for head posture abnormalities when
Msete Turn ilevatton Tilt the muscle or muscles remain paretic. Conse-
quently, it is likely that a noncomitancy of long
Rig ht lateral rectus R , duration can be detected by means of head pos-
Right medial rectus L _ ture observation.
Rtght superior rectus R Up L
Right inferior rectus R Down R
Right superior L Down L Subjective Testing
oblique Subjective comitancy testing, when feasible, is
Right inferior L Up R usually more precise than are objective testing
oblique methods. The patient may be able to notice a very
Left lateral rectus L __ small displacement of two images resulting from
Left medial rectus R - misalignment of the visual axes. Observations of
Left superior rectus L Up R small deviations sometimes is difficult for the
Left inferior rectus L Down L examiner, making objective testing less sensitive.
Left superior R Down R This is particularly true for cyclo deviations, for
oblique which subjective testing must often be relied on for
Left Inferior oblique R Up L accurate diagnosis.
L = teft; R right.
There are, however, disadvantages to subjective
testing. This type of examination is greatly depen-
dent on the cooperation of a capable and aware
patient. An uncooperative, dull, or unperceptive
patient gives either invalid or no results. Objective
the patient. Interpretation of abnormal posture is testing must be relied on in such cases. The pres-
facilitated by the knowledge that the patient's face ence of anomalous retinal correspondence (ARC)
points in the same direction as the DAF of the also may invaldate subjective findings, because
affected muscle (Tables 4-8 and 4-10). For exam- the objective and subjective angles are different.
ple, a paretic right superior oblique muscle causes Moreover, the subjective angle itself is often vari-
a patient to turn the head abnormally to the left able when this condition is present. (ARC is dis-
and to lower the chin. (The right superior oblique cussed in Chapter 5.)
muscle is in its DAF when the right eye is turned to
the left and downward.)
Single-Object Method
Another similar rule explains the presence of
an abnormal head tilt. A paretic right superior The traditional way to make a patient aware of
oblique muscle, for example, causes the head to pathologic diplopia is by using a single target (see
be tilted toward the left shoulder in habitual natu- Chapter 1). If a patient has an exotropic deviation,
ral seeing conditions. Because the right superior a bright penlight in a darkened room should be
oblique muscle is an intortor, it moves the top of perceived by that patient as a double image. A
the eye in a leftward direction and, because the deviating right eye sees the image of a light to the
muscle is weak, the patient's head tilts in a left- left of the fixated light seen by the left eye. This is
ward direction as compensation. The rule to remem- heteronymous (crossed) diplopia and the type nor-
ber is that the compensatory abnormal head tilt is mally expected with exo deviations. In contrast,
in the same direction as the torsional movement homonymous (uncrossed) diplopia is normally
of the eyeball that would result from the muscle's expected with eso deviations.
contraction. Two rules apply when testing for noncomitancy
Diagnosis is complicated when more than one using the single-object method. First, the patient
muscle is affected. Nevertheless, the patient is should perceive the target seen by the deviating
likely to have an abnormal head posture and one eye in an opposite direction from that in which the
that tends to be biased toward the DAF of the most eye is deviating. Henee, an exotropic right eye
severely affected muscle. Mltiple pareses require sees the image to the left, whereas an esotropic
Chapter 4 123
right eye sees the image to the right. Second, the because the white background is more intense
distance between the diplopic images becomes than the red Unes and spots; they are, conse-
greater when there s an ncrease in either an quently, washed out. They are visible, however, to
underaction or an overaction during versions. the eye wearing the green filter. The lines and spots
Neutral ization with lose prisms, however, can appear as dark gray, because the red hue is not
determine the direction and magnitude of the sub- transmitted by the green filter, but the white back-
jective angle of directionality, which is the same as ground is. A convenience when interpreting the
the objective angle of deviation of the visual axes if results s that the directions in which the flashlights
there s normal retinal correspondence. are pointed correspond to those of the visual axes.
The subjective angle of directionality (angle S) Figure 4-27 illustrates a recording chart for the
can also be measured by using a black tangent Hess-Lancaster test. The separation between the
A
screen and can be performed in ail nine diagnostic lines represents approximately 7 . The fixation spots
positions of gaze. The examiner marks on the screen are five squares from the center; therefore, they are
A
the separation of the diplopic images reported by 35 (almost 20 degrees) laterally displaced. The
A
the patient. If a 1 -m test distance s used, each centi- spots are placed 28 vertical ly above and below the
A
meter displacement of the images represents 1 . ievel of the central fixation spot. Because of chang-
Nevertheless, many practitioners find the single- ng tangent vales, the magnitude represented by
object method confusing, because they have to each separation of lines is variable. The prism
think in reverse as to direction of the deviating eye diopter valu diminishes as fixation changes from
and the diplopic image. This confusin is eliminated the primary position to the periphery. Despite this
by employment of the two-object method. mathematic variable, it is general ly unnecessary to
compnsate for these changes for clinical purposes.
Two-Object Method A A
The mathematic error amounts to only 1 or 2
Two fixation targets are required for the two-object within the range of the test. Fixations would have to
A
method. Special filters, usually red and green, are be much greater than 35 away from the primary
used. The right eye sees only one target (customar- position before tangent vales would crate a signif-
ily through a red filter), and the left eye sees the icantly invalidating factor. The chart also includes
other target (customarily through a green filter). the ames of the 12 extraocular muscles. The loca-
The Hess-Lancaster test may be custom-made by tion of each represents the DAF for those particular
drawing red lines on a white board to form a grid, muscles.
a rectangular coordnate tangent screen with a The following procedure is recommended for
white background and red lines and red fixation performing the Hess-Lancaster test. To evalate
spots (Figure 4-26). The red lines and spots are the right field (i.e., to test the muscles of the right
invisible to the eye wearing the red filter. This is eye), the patient puts on red-green spectacles
124 Chapter4
Right Field
LeftField
fcR
FIGURE 4-27Form used for chart-
ng 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 specta- the right of the central target to achieve the per-
cles stay in place throughout testing for both the ception of superimposition of the red and green
right and left fields. The room is dimly illumi- images (Figure 4-28). Note that a vertical streak
nated. While the examiner holds the green pro- projected by each flashlight would be preferable
jecting flashlight, the patient holds the red one. to a spot, because a cyclo deviation can be
Test distance from the patient to the center of the revealed at each testing position.
screen is 1 m. The deviation in the primary posi- If the patient is either esotropic or esophoric, the
tion s measured first. The examiner projects the red spot should be projected to the left of the fix-
green light onto the central spot, and the patient ated green spot. The rule is that the patient projects
attempts to superimpose the projected red spot of the light in the same direction as that of the deviat-
light (being seen only by the right eye) with the ing eye. This is direct foveal projection; interpreta-
green spot, which is seen and fixated only by the tion is facilitated by not having to think in reverse,
left eye. An exotropic or exophoric patient with a as in the single-object method.
deviating right eye will point the red flashlight to If the patient does not understand this testing
procedure, which often is true of young children, it
FIGURE 4-28Diagram showing patient's perception of superimposi,- is instructive to remove the colored spectacles and
tion on the Hess-Lancaster test n an example of an exo deviation of to ask the patient to superimpose the projected
itod Targtt 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
Red Filter 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 actu-
ally are separated. This observation is helpful in
explaining the nature of a deviation to the parent
of a young patient.
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 fil-
After measuring the subjective angle n the pri-
ters, and one n which the left eye s the dominant eye. mary 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 125
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 exam- ing eye, whereas the circles represent the fixation
iner directs the red spot to the central fixation cir- spots for the fixating eye. An outline of the eight out-
cle, and the patient fixates with the right eye and side Xs is made by connecting them to form an
tries to superimpose the green spot with the red. enclosure. The rea of the enclosure of each field s
All nine positions of gaze are measured for the left compared. In this example, the right enclosure s
field, following the same procedure as is used n smaller than the left, which means that the paresis
testing the right field. It s important that the red fil- causing the underaction is n the right eye. The left
ter remain over the right eye and the green over the enclosure is larger, indicating overaction by the left
left eye, so that this method can be followed con- eye, thus graphically illustrating the effect of Her-
sistently; otherwise, nterpretation of results may ing's law. For clarification with a contrasting exam-
be confusing, particularly true when two or more ple, an exotropic deviation due to paresis of the
affected muscles are nvolved. right medial rectus s shown n Figure 4-30. The rea
Exampies are provided to explain i nterpretation of the enclosure for the right field s much smaller
of the measured deviations. Figure 4-29 shows the than for the left. Henee, the overaction of the left
charting of a paretic right lateral rectus muscle. In lateral rectus muscle s large when the paretic right
right gaze, the paretic right lateral rectus is n its medial rectus muscle s in its DAF.
DAF and s underacting. The left medial rectus s n This method of charting s very useful when two
its DAF and is overacting (Hering's law). The As rep- or more muscles are affected. Figure 4-31 illustrates
resent the positions of the spots seen by the deviat- an example of paresis of both the right lateral rectus
r.l
and the right superior oblique muscles. Besides the a strabismus is not present any of the time under
similar effect of the paretic lateral rectus, there s natural habitual seeing conditions, the patient s
also an underaction in the DAF of the right superior necessarily classified as either orthophoric or het-
oblique, which results in an overaction of its yoke erophoric (f there is a latent deviation of the visual
muscle, the left inferior rectus. The two underacting axes). More patients are heterophoric than ortho-
muscles of the right eye cause the enclosure of the phoric because there is usually at least some devi-
right field to be much smaller than that of the left ation present, even though it may be small. Any
field. Visual inspection of muscle field charting latent deviation (1 A or greater) is classified as het-
facilitates diagnosis of the affected muscles. erophoria. As in strabismus, the heterophoric devi-
The Hess-Lancaster test is the most sensitive of al I ation may be horizontal, vertical, or torsional.
cimical tests for noncomitancy. There are, however, Strabismus s classified as intermittent if t s
some pitfalls, including ARC, deep suppression, and present from 1% to 99% of the time. A synony-
poor cooperation by the patient. If any of these mous term for intermittent s occasional. The latter
exists, testing may have to be performed entirely by term is used by some clinicians, but we believe it
objective means. Furthermore, results of one test implies a state of nfrequency: The semantic con-
should confirm the results of another; therefore, t is notation to most practitioners is that the deviation
wise to perform different types of tests on a patient is manifest only once in a while, which may not
when noncomitancy is suspected. Management of state the true situation. It would be misleading, for
cases of noncomitancy s discussed in subsequent example, to a strabismus that s present 95% of the
chapters, particularly Chapters 8 and 15. time as occasional. We believe the term intermit-
tent is more neutral as to frequency, and we rec-
ommend t along with including the estimated
FREQUENCY OF THE DEVIATION percentage of time a strabismus is present at far
Next in importance to comitancy evaluation is and at near.
determination of the frequency of a manifest devia- Table 4-11 classifies frequency of strabismus based
tion. This knowledge helps the practitioner to assess on the percentage of time (during normal waking
the status of a patient's binocularity. For example, a hours) that there is a manifest deviation of the visual
patient who is strabismic 95% of the time has axes. Strabismus s constant when t s present 100%
poorer control on bifoveal fusin than does a of the time. Synonymous terms include continuous
patient who is strabismic only 5% of the time. strabismus, permanent strabismus, and absolute stra-
bismus. We prefer the term constant.
An intermittent strabismus may be either peri-
Classification odic or nonperiodic, although in most cases it is
Frequency refers to the amount of time a deviation the latter. If a strabismus is to be called periodic,
is manifest, which may range from 1 % to 100%. If its occurrence must be predictable and regular. A
Chapter 4 127
as small as 3 degrees. Smaller cyclo deviations far deviation appears to have good test-retest
usually must be detected and measured by subjec- repeatability.15
tive means. Cyclo deviations require the use of a Maddox
rod for each eye. If a Maddox rod is placed before
the right eye with its axis at 180 degrees and
Subjective Testing another Maddox rod with its axis at 180 degrees s
The subjective angle of directionalization may be placed before the left eye, two vertical streaks may
determined with two targets (e.g., Hess-Lancaster be seen (assuming a horizontal deviation s also
test) or, more commonly, with a single target, present to prevent the superimposition of the two
using any of several methods for either phorias or vertical streaks). If a cyclo deviation s not present,
tropias. The horizontal subjective angle is easily the streaks appear paral le. If, however, the right
determined with the von Graefe method using ver- eye s exotropic and excyclotropic, the top of the
tical prism dissociation. This is performed rou- leftward streak (seen by the right eye n this exam-
tinely to measure phorias n primary eye care ple) will appear inclined away from the vertical
examinations. As the patient sees the diplopic streak seen by the fixating left eye. In regard to the
mages of the single target (e.g., penlight), the direction of the perceived slant, the rule s that the
examiner introduces a sufficient horizontally ori- patient perceives the streak as slanting n the direc-
ented prism, either B! or BO, to crate vertical tion opposite the cyclo deviation of that eye, as
alignment of the two images. This is the subjective llustrated and clarified n Figure 4-32.
angle of directionalization. Another subjective method for determining the
Colored filters can be used n conjunction with direction of the deviation, when there is normal
the von Graefe method, or they can be used with- retinal correspondence, s the use of the phi phe-
out the vertical dissociation. If, for example, a red nomenon, which is a patient's perception of move-
lens s placed before a right esotropic eye that is ment of a stationary single target during rapid
being suppressed, the filter creating a color differ- altrnate occlusion. The apparent movement s
ence between the eyes may serve to break the sup- perceived when a deviation of the visual axes is
pression. In some cases n which suppression s present. The phi phenomenon s based on the stim-
very deep n the deviating eye, the red filter should ulation of disparate retinal points and not on eye
be switched to the fixating eye. This reduces the movements. For illustration of this point, refer to
intensity of the light entering the eye and acts as a Figure 4-4, n which the right eye s shown to be
mild occluder, giving an advantage to the deviating esotropic. On rapid altrnate occlusion, the right
eye. In any event, assuming normal retinal corre- eye can be briefly exposed while an occluder is
spondence, the patient should perceive homony- shifted from the right to the left eye. The fixated tar-
mous (uncrossed) diplopia when there s an eso get will appear to move to the right (opposite
deviation. If the patient has an exo deviation, the movement from that of the occluder). When the
perception should be heteronymous (crossed) occluder s shifted back to the right eye, the target
diplopia. will appear to move to the left (opposite direction).
The Maddox rod can also be used to determine In cases of exo deviations, the shift of the phi
both the direction of the subjective angle and the phenomenon is the same as the motion of the
magnitude. Although the original design by Mad- occluder. In vertical deviations, when the hyper
dox was a single, elongated, cylindric lens, most deviated eye s exposed, the apparent movement is
clinicians prefer mltiple rods for dissociative test- downward. If the patient has a torsional deviation,
ing. Nonetheless, this method that uses mltiple a vertical line is used for fixation, and a shift in the
rods s known as the Maddox rod (singular). If the inclination during altrnate occlusion reveis a
Maddox rod s placed with its axis at 180 degrees cyclo deviation. If, for example, a patient has an
(rod horizontal) before the right eye, the eye excyclotropic eye, the top of the line will appear to
should see a vertical streak. If, for example, the move in the same direction as the occluder. If the
patient is exotropic (or if exophoric), the vertical eye has an incyclo deviation, the top of the line
streak should be seen to the left of the fixation will appear to move in the opposite direction.
light. If the patient has an esotropa (or esophoria), If there is no deviation of the visual axes, the phi
the vertical streak should be seen to the right of the phenomenon should not be perceived. There may
fixation light. The Maddox rod measurement of the also be no perception of the phi phenomenon f the
130 Chapter 4
altrnate occlusion s too rapid so that the patient s carefully controlled, particularly at near, if measure-
allowed to see as though looking through the blades ment of horizontal deviations is to be valid (because of
of a fan. We recommend switching the occluder effects of accommodative convergence). The best
approximately every 0.5 second to achieve the most objective test for measuring the magnitude of devia-
reliable results for the phi phenomenon. tions for far or near is the altrnate cover test com-
bined with lose prisms. There is an advantage of
using lose prisms rather than prism racks, because
MAGNITUDE OF THE DEVIATION both the horizontal and vertical components of a devi-
Unless otherwise specified, the magnitude ofthe devl- ation can be conveniently measured simultaneously.
ation customarily refers to the angle of deviation of the In addition, the prism rack is bulky, making measure-
visual axes when fixation is in the primary position. ment of more than one component awkward. For
This parameter should be measured for both the far- example, to use the prisms in measuring an esotropa
point (optical infinity) and the nearpoint. The most fre- of the right eye that also has a hypertropia, two lose
quently used fixation distances are 6 m (20 ft) for far prisms, one BO, the other BD, are simply placed
and 40 cm (16 in.) for near. Accommodation must be together between the occluder and the right eye.
Chapter 4 131
should be recorded. This often s associated with relation between crossed dominancy and learning
infantile esotropa or ARC (or both). The midline disabilities was once considered by some to be sig-
switch also is referred to as a cross-fxation pattern: nificant, although modern thinking tends to disre-
Although each eye is used at various times, this is gard this association.
not truly an alternating strabismus as regards
switching fixation in the primary position of gaze.
VARIABILITY OF THE DEVIATION
EYE DOMINANCY There are many influences on tonic convergence
which, n turn, affect the magnitude of a deviation.
Eye dominancy refers to the superiority of one eye
According to Maddox (see Chapter 1), tonic con-
over the other, in either the motor or sensory
vergence s one of the four components of conver-
realm. Sighting tests that determine the eye pre-
gence, the other three being accommodative,
ferred for fixation are examples in the motor realm.
fusional (reflex), and proximal (psychic).
In strabismus, the terms eye preference and eye
In cases of heterophoria, changes n tonic con-
dom'mancy are used synonymously. The unilateral
vergence are not obvious, unless dissociative test-
cover test can be used to determine the fixating
ing is performed and each day's findings are
eye n strabismus. If the deviation s large enough
compared with those obtained on other days.
to be observed, the Hirschberg test is a practical
However, significant changes in cases of strabis-
means for such evaluation.
mus may be observable and can have a striking
In heterophoria, n which the deviation s latent
effect on the patient's appearance if the deviation
and not observable except on dissociation, sighting
changes from being just noticeable to being highly
tests such as the hole-in-the-card test should be used.
noticeable. Cosmetic appearance of a strabismus is
With both hands, a patient holds, at arm's length, a
often a patient's greatest concern. It s important
card having a small hole in the center and sights a
for the physician to understand this and to have
distant fixation target. The clinician alternateiy
empathy for a patient's feelings in this regard.
occludes each of the patient's eyes to determine
Changes n the magnitude of deviation may occur
which eye the patient is using to sight the target.
for various reasons. Fatigue, emotional stress, medi-
The nearpoint of convergence s another means
cation, illness, and other factors may be involved.
of determining which eye s superior in motoric
Variation n the magnitude of the angle of deviation
functioning. The eye that stops first in following the
may cause a latent deviation to become manifest A
advancing target s considered to be nondominant,
case of intermittent strabismus is usually more notice-
at least for very near fixation distances. Testing of
able than a case of constant strabismus. It should be
accommodative facility (monocularly) and fixation
noted, however, that ntermittence is not usually the
disparity are other ndices of motor dominancy
result of a change in tonic convergence. In most
(see Chapters 2 and 3).
cases, ntermittence probably involves the power of
Dom inancy testing n the sensory realm
compensatory fusin, whereby a deviation may or
includes retinal rivalry, color fusin, and suppres-
may not be held latent.
sion and apples particularly to cases of heteropho-
ria. (In strabismus evaluation, eye dominancy
generally s based on the finding of which eye s
COSMESIS
preferred for fixation.) Dominancy should be
determined at far and near, as there may be a dif- In addition to magnitude, its variability, and strabis-
ference when fixation distance is changed. The lat- mic i ntermittence, certain anatomic factors affect
ter situation is an example of mixed dominancy, cosmesis. The list of such factors presented in Table
meaning that one eye s preferred for some func- 4-1 7 ndicates whether each s favorable or unfavor-
tions but not for others. able to the appearance of patients with esotropa or
In evaluation of heterophoria, eye dominancy is exotropia.
determined by testing for both sensorial and Clnicans should not judge cosmesis exclu-
motoric superiority between the two eyes. In the sively on the bass of the magnitude of the deva-
past, great interest was shown in crossed domi- ton. Rather, all factors must be considered. For
nancy (i.e., the dominant eye and the dominant example, the recommendaton to undergo surgery
hand being on opposite sides of the body). The for cosmetic reasons may be given to a patient hav-
134 Chapter 4
Several anomalous conditions can develop sec- In other words, the strabismus may be the end
ondary to the onset of a deveiopmental strabismus, result rather than the cause of the anomalous sen-
particularly of early origin. These nclude Suppres- sory conditions.
sion, amblyopia, and anomalous Correspondence.
These conditions and the appropriate testing meth-
SUPPRESSION
ods for them are discussed in this chapter.
Although t s customary to think in terms of the When a strabismus occurs, the affected individual
deviation causing these adaptive conditions, t is may experience pathologic diplopia or confusin
also possible that the process may work in reverse. (or both). Suppression is the defense mechamsm
136 Chapter 5
O.D
c. O.O. FUNDUS
the diplopia s called homonymous, or uncrossed. If, some cases, however (e.g., a large-angle strabis-
however, the diplopic mage were to fall on the tem- mus with amblyopia of long standing), it appears
poral retina of the deviating eye, heteronymous that most or all of the binocular visual field of the
(crossed) diplopia would occur. For the redundant deviating eye is pathologically suppressed.
ocular mage to be eliminated, the target point on How does the suppressing strabismic patient per-
the nasal retina of the right eye must be suppressed. ceive visual objects in space? Such a patient does
Jampolsky9 referred to this location as the "zero experience continuity of visual space across the
measure" point (point zero). This point and its adja- visual field, similar to the individual having normal
cent rea must be suppressed to avoid diplopia. binocular visin (Figure 5-2a). However, there may
Peripheral diplopia may occur if the deviation is be a slight decrease or increase in the horizontal
larger than Ranum's fusional reas n the peripheral size of the visual field, depending on whether the
binocular field, but the combined influence of low deviation is esotropic (see Figure 5-2b) or exotropic
resolution, suppression, and selective attention to (see Figure 5-2c), respectively. Fortunately, a strabis-
the fixated target usual ly prevents the perception of mic patient who is free of ocular pathology per-
double images n these distant locations. ceives no gaps (missing portions) n the visual field.
Whereas point zero (the target point, sometimes Suppression of the turned eye occurs only within
designated as T) usually s suppressed, the fovea in the binocular overlap rea. Suppression s not obvi-
the deviating eye s suppressed even more ous to the individual except indirectly, possibly
intensely. If this were not the case, then two dis- because of deficient stereopsis; a vivid spatial sense
similar images would be superimposed, as each of three-dimensionality often is missing, depending
fovea is pointing to a different location within the on the extent and depth of the suppression zone.
binocular visual field. This intolerable situation is The extreme peripheral lateral fields of each eye are,
called confusin. Suppression of the fovea of the however, normal. These temporal crescents, approx-
deviated eye occurs more quickiy and deeply than imately 30 degrees on each side, cannot be sup-
at point zero because foveal visin is usually the pressed. The crescents are neurally subserved only
location of attention. Clinically, strabismic individ- by monocular fibers from the nasal retina of each
uis typically do not report confusin, but many eye. The suppressed eye s unresponsive to binocu-
do have symptoms of diplopia. lar stimulation but s responsive to the "monocular"
It is probable that suppression begins first at the stimulation of the peripheral nasal retina.
fovea when a horizontal deviation of the visual Foveal suppression may also be found n nonstra-
axes becomes manifest, as in Figure 5-1; later, bismic patients. Anisometropia may cause image
point zero s also suppressed. Afterward, a patho- size difference on the retina of each eye (aniseiko-
logic zone of suppression encompasses the rea nia) and also a difference n clarity. Suppression s,
between the fovea and point zero of the deviating therefore, necessary to elimnate the confusin aris-
eye. The vertical dimensin of this zone s usually ng from the resulting supermpositon of dissimilar
smaller than the horizontal dimensin. The shape ocular images (.e., one image being larger than the
of the zone resembles the letter D, according to other). The suppression zone in such cases is rela-
Jampolsky,9 and the vertical demarcation at the tively small and encircles only the fovea, as there is
fovea resembles a hemianoptic visual field defect. no extrafoveal point zero. Therefore, confusin, and
Although this is a theoretical model of the sup- not diplopia, s the problem. Foveal suppression is
pression zone, clnica! findings suggest that these found also n patients with large heterophoria if
demarcations are not always so clear-cut. Pratt- fusional vergence compensaron is poor. The mech-
Johnson and MacDonald10 showed that suppres- an ism is not fully understood, but t s likely that ver-
sion does not exclusively involve the nasal retina gence stress or fixation disparity can initiate a
in esotropes and the temporal retina in exotropes, suppression response.
but it may extend in both directions regardless of Suppression may be classified by size and inten-
the direction of the deviation. The shape and size sity. In regard to size, suppression s classified as
of the suppression zone depends on the targets being either central or peripheral. If a patient has
used and the way the test is performed. The sup- central suppression, the edge of the suppression
pression "scotoma" s, therefore, considered rela- zone can extend to 5 degrees from the center of
tive rather than absolute, appearing more extensive the fovea. Beyond this limit, suppression s consid-
and deep in the hemiretina toward point zero. In ered to be peripheral (Table 5-1). It must be
138 Chapter 5
Binocular
overlap
rea
remembered that the limits of the suppression ditions (e.g., Pola-Mirror), the patient will more
zone depend on the testing conditions and the size likely suppress an eye. Illuminated targets, such as
of thetargets used. a penlight or Worth lights, become less natural by
Intensity of suppression vares on a continuous lowering room illumination.
scale from shallowto deep (Table 5-2). This is nec- In effect, intensity is described in terms of the
essarily a qualitative determination. It is made by testing procedure that is required to break (elim-
finding the ease with which suppression can be nate) the suppression response. Some of the meth-
broken by using various testing procedures. The ods commonly used to test the intensity of
more unnatural the environment (laboratory type suppression are Usted in Table 5-2. The more natu-
of testing conditions), the less likely is suppression. ral tests appear at the top of the list, with the less
For example, the Worth dot test using red-green fil- natural following in descending order. Using this
ters in a dark room is relatively unnatural and as a guide, it is reasonable to assume, for example,
serves as a strong stimulus to break through sup- that a strabismic patient who notices pathologic
pression. Conversely, in more natural seeing con- diplopia when viewing a penlight in an illumi -
Chapter 5 139
Naturalness of Intensity of
Testing Method of Testing Instrumentation Suppression
which tends to overeme suppression. For these be placed precisely at the strabismic angle of
reasons, the Worth dot test at near, particularly in deviation. Superimposition, fat fusin, and
a dark room, is a strong stimulus to break suppres- stereofusion targets (i.e., first-degree, second-
sion. The clinician must also take nto consider- degree, and third-degree, respectively) are used
ation any change n the patient's strabismic to assess the patient's sensory fusin ability. If the
deviation from far to near that has previously been patient has second-degree fusin, vergence
measured on the cover test. Another problem n ranges can be measured relative to the strabismic
nterpretation s that a light is not a good stimulus angle. In addition, the extent and ntensity of sup-
for accommodation, and therefore an accommo- pression can be easily evaluated.
dative response may be inadequate, thereby The Synoptophore is one of the most popular
affecting the magnitude of strabismic deviation. It major amblyoscopes (Figure 5-4). Each tube of the
must also be recognized that red-green filters tend Synoptophore includes a mirror placed at 45
to dissociate the eyes and may cause a latent devi- degrees and a +7-diopter (+7-D) eyepiece lens.
ation to become manifest. The dark room condi- Test targets are placed at optical infinity. Figure 5-5
tions exaggerate this tendency, because the only shows the direction of movement of a carriage arm
effective fusin stimulus s the small, single, white to crate base-in and base-out prism demands.
dot. Typical first-degree (superimposition) and second-
Despite these complications, an experienced cli- degree targets for sensory fusin assessment are
nician can obtain much nformation about a shown n Figures 5-6 and 5-7, respectively. The
patient's suppression and sensory fusin. For exam- carriage arms are aligned to the patient's mea-
ple, suppose that a patient has a comitant, intermit- sured, subjective angle of directionality (discussed
A A
tent exotropia of 15 at far and 18 at near. In a later in this chapter).
lighted room, the W orth dot responses of this Initially, superimposition targets are placed n
patient are three dots at far and four dots at near. the amblyoscope, and equal illumination is used
These responses indcate that the patient s sup- for the two eyes. If one of the targets is not seen,
pressing the red-filtered eye at far but s sensorially suppression is indicated. Regarding suppression
fusing at near. In the dark room, assume that the zone size, slide G48 (the fish tank) subtends angu-
patient reports five dots at far and at near. The lar dimensions of 1.5 degrees vertical and 2
patient s showing a relatively shallow central sup- degrees horizontal and are useful for foveal and
pression indicated by suppression at far in the parafoveal suppression testing (see Figure 5-6). The
lighted room, with a small retinal mage and diplo- G2 slide (sentry box) subtends angles of 15 degrees
pia n the darkened room. Inadequate fusional con- vertical and 9.5 degrees horizontal. The soldier
vergence also s indicated if a fusin response and the house slides, therefore, are useful for test-
occurred at near n a lighted room yet fusin was ing peripheral suppression. The other superimposi-
broken in a darkened room. tion targets in these examples, X and square, test
Preschool children often have difficulty counting for foveal suppression.
accurately, so results of the Worth dot test for these An excellent example of second-degree targets
children may have questionable validity. A less containing both peripheral and central suppression
ambiguous test is Bernell's three-figure test, which clues are those illustrated n Figure 5-7. Again, the
also requires the use of red-green anaglyphic glasses. targets are placed n the amblyoscope at the sub-
Three relatively large figures are presented on the jective angle with equal illumination for the two
face of a flashlight; a red little girl, a green elephant, eyes. A normal fusin response would be the
and a white ball. This presentaron seems to commu- report of seeing a single bug having four wings and
nicate well with most children older than 2 years, three dots on its body. Any missing dots would
but because the suppression controls are larger and indcate central suppression, whereas missing
brighter than the standard Worth dot test, evidence of wings would indcate peripheral suppresson. If
mi Id suppression may be missed. suppression s noted, ntensity can be assessed by
simply changing the relative illumination of the
Amblyoscope Workup targets. The target of the dominant eye can be
The major amblyoscope (e.g., Clement Clarke dimmed until the patient sees the missing clues
Synoptophore; see Appendix J for location of sup- with the suppressing eye. The larger the difference
plier) has the advantage that various targets can n illumination between the two eyes, the deeper is
142 Chapter 5
FOR MODEL 2051
MECHANI CAL
KEY 1. Carrying handles (2).
2. Inlerpupillary distance seleclion
controla (2).
3. Interpupillary distance scale.
4. Chinrest height control.
5. Chinrest.
6. Forehead rest.
7. Breathshield.
8 Handles for adjustment of horizontal angla between
tubes(2).
9. Horizontal deviation scales (2).
0. Vertical deviation scales (2).
1. Vertical deviation controls (2).
2. Torsional deviation scales (2).
3. Torsional deviation controls (2).
4. Elevation and depression scales (2).
5. Elevation and depression controls (2).
6. Slide carriers (2).
7. Slide ejectors (2).
8. Auxiliary lens holders (2).
18A. Eyepiece lens (removable) (2).
19. Horizontal vergence scale.
20. Horizontal vergence controls (2).
35 21. Tube locking controls (horizontal) (2).
22. Central lock.
32. Lever for swivelling opal screen from optical pathway
(2). (Model 2052 only.)
ELCTRICA!.
23. On/Off switch.
24. Mains current nput plug and socket.
25. Indicator lamp.
26. Voltage selector.
27. 6V. Lampholders (sude illumination) (2).
27A Lamphouse locking lever (2).
28. 12V. Lampholders (after-images and Haidinger's
brushes).
29. Hand flashing switches (2).
30. Dimming rheostats (2).
31. Selector switch.
33. Plug and socket connections to 6V. lamps (2).
34. Plug and socket connections to 12V. lamps (2).
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 sup- When third-degree fusin sudes are used, the
pressed target can also provide an ndex to the targets should again be positioned at the patient's
intensity of suppression. (These methods for break- subjective angle. If stereopsis is not perceived,
ing suppression are discussed in the sections on suppression should be suspected. Some patients,
therapy in Chapter 12.) Subsequent to this evalua- however, have been found to be stereoanoma-
tion, the extent and depth of the suppression zone lousthat is, a certain class of stereodisparity
are recorded. detectors (e.gv crossed disparity detectors) is con-
Chapter 5 143
a.
b. .-
X D
G73 EX G74 SQUARE
FIGURE 5-5Schematic of a major amblyoscope. a. Carriage arm FIGURE 5-6Superimposition (first-degree fusin) sudes used in the
moved toward examiner results in a base-out demand. b. Carriage Synoptophore. G1 and G2 test for peripheral suppression. G47 and
arm moved away from the examiner results in a base-in demand. G48 test for parafoveal suppression. G73 and G74 test for foveal sup-
pression.
genitally missing. This condition s independent of developmental loss of acuity during early child-
suppression. hood due to one or more of the preceding etio-
logic factors. For consistency with health science
classifications, amblyopia must be described by
AMBLYOPIA the associated etiologic factors.
The prevalence of any condition depends on
Amblyopia is defined as the condition of low or
how the condition is defined and the sampling
reduced visual acuity not correctable by refractive
characteristics of the surveyed population. For
means and not attributable to ophthalmoscopically
these reasons, there s considerable variation n the
apparent structural or pathologic anomalies or proven
prevalence of amblyopia reported in the profes-
afferent pathway disorders.1 The word amblyopia lit-
sional literature. In a major review of the topic by
erally means "dullness of visin." Best correctable
Ciuffreda et al.,12 their most accurate estimates
visual acuity worse than 20/30 (6/9) is considered to
were 1.6% for military personnel, 1.8% for pre-
meet a descriptive criterion for amblyopia. Generally
school and school-aged children, and 2.3% for
speaking, amblyopia of 20/30-20/70 s mild (shal-
low), 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 let-
ters 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 recog-
nized amblyogenic factor (e.g., constant unilateral FIGURE 5-7Target designed to test
second-degree fusin while moni-toring peripheral suppression (wings)
strabismus, anisometropia, or high refractive error
and central suppression (dots).
bilaterally [isoametropia]). Amblyopia refers to a
144 Chapter 5
clinical patients seeking visin care. Premature loss in strabismic ambiyopia tends to be worse
infants are particularly vulnerable to developing than in anisometropic ambiyopia, but the severity
ambiyopia (21%) or strabismus (28%) in the first 3 of ambiyopia is not consistently correlated with
years of ufe, according to Schalij-Delfos et al.13 the size of the strabismic deviation.14 When both
strabismus and anisometropia coexist, the ambiyo-
pia tends to be deeper than in the presence of only
Classification one of the conditions.
Ambiyopia usually is considered to arise from a Because constant unilateral esotropa is much
deprivation of form visin, abnormal binocular more prevalent than constant unilateral exotropia,
interaction (i.e., suppression), or both during early ambiyopia is more frequently associated with
development, probably before 7 years of age. The esotropa. Most esotropic patients have constant
form deprivation can be either unilateral or bilateral strabismus, whereas most exotropes exhibit inter-
but most often occurs unilaterally. Those patients in mittent strabismus. Helveston 15 found ambiyopia
whom visual acuity is reduced significantly due to in 80% of his sample of esotropes but in only 17%
obvious ocular disease or in whom there is proven of the exotropes. If reduced unilateral acuity is
pathology in the visual pathways are classified as associated with ntermittent strabismus in the
having low visin, in contradistinction to ambiyo- absence of anisometropia, the clinician should
pia. Organic ambiyopia, however, is the term some- suspect an organic cause.
times used (rather than low visin) in certain cases Strabismic ambiyopia is highly associated with
of reduced visin in which ocular pathology is not eccentric fixation (EF). When the amblyopic eye is
obvious (even though there may be a small central forced to pick up fixation, the time-averaged posi-
scotoma in some cases). Examples include a reduc- tion of fixation is not the fovea but an extrafoveal
tion of acuity from nutritional factors, tobceo, alco- point. The patient's sense of straight-ahead or ocu-
hol, salicylates, and other toxic agents. Another type locentric direction has also shifted to the extrafoveal
of reduced visual acuity that often is labeled as psy- point or rea used for fixation, which may explain
chogenic ambiyopia is due to causes such as hys- why EF develops initially.
teria or malingering. It is fairly common in children
and adolescents and occurs sometimes in adults Anisometropic Ambiyopia
who are in stressful situations. Perimetric studies Some clinical studies indcate that anisometropia
usually reveal tubular fields. In this book, however, is the most common cause of ambiyopia.15"17
we discuss developmental ambiyopia due to form However, in a retrospective study of 544 ambly-
deprivation and suppression rather than organic and opes in whom microtropia was assessed, Flynn
other causes of reduced visual acuity. and Cassady18 found pur anisometropic ambiyo-
A current classification system for ambiyopia is pia to be the least prevalent type. They reported
based on the specific etiology of the condition: 20% of the cases of ambiyopia were due solely to
strabismic ambiyopia, anisometropic ambiyopia, anisometropia, 48% were purely strabismic, and
isoametropic ambiyopia, and image degradation 32% were both anisometropic and strabismic.
ambiyopia. Anisometropia deforms foveal images in a different
way than does strabismus. In strabismus, the two
Strabismic Ambiyopia foveas are presented with two different images
Ambiyopia may occur as a result of long-standing (confusin), a disparity of form perception, thus
suppression when there is constant unilateral stra- strongly stimulating suppression. In anisometropia,
bismus at all viewing distances during early child- the suppression is less intense; the dissimilarities of
hood. The foveal rea is suppressed to prevent the foveal images are in relative clarity, size
confusin. Subsequently, there is active cortical (aniseikonia), and contrast.
inhibition of point zero in the deviating eye and The amount of anisometropiapresuming no
often of the entire binocular overlap rea in the treatment (i.e., optical correction or visin training)
amblyopic eye. Stereopsis is usually severely is givendirectly influences the depth of ambiyopia
reduced or absent in strabismic ambiyopia. The and its prevalence.19-20 A 1-D difference in refrac-tive
suppression mechanism may be similar in strabis- error is considered to define anisometropia, but this
mic and anisometropic ambiyopia, but it may be amount does not usually cause ambiyopia to
more intense in strabismic ambiyopia. The acuity develop. However, Tanlamai and Goss21 found an
Chapter 5 145
30
About a century ago, Worth referred to the acuity
TABLE 5-4. Visual Defdendes Assodated loss due to lack of development as amblyopia of
with Amblyopia arrest and the acuity loss due to interference with
consolidation as amblyopia of extinction. He
believed the former to be irrecoverable by patching
Sensory testing Decreased visual acuity Decreased
or other therapy and the latter to be reversible
contrast sensitivity for fine detait Spatial
through proper treatment. This view of amblyopia
uncertainty Monocular spatial distortion Increased
still strongly influences many clinicians and scien-
perception and reaction times Suppresslon
tists alike, although aspects of it do not appear to be
Reduced stereopsis Motor testing
supported by recent evidence. Even though infor-
Unsteady fixation: ncreased drift amplitude
mation about the specific nature of the visual dfi-
Eccentric f ixaton Defective saccades: increased 30
cits in amblyopia has greatly expanded, Worth
latency, reduced peak
provides a conceptual framework that still guides
velocity, fnaccuracy Defective pursuits: jerkiness
clinical decisions, for better or worse, and serves as
Reduced and asymmetric optokinetic nystagmus
a reference for addressing research questions. (Fur-
responses
ther discussion of the concepts of arrest and extinc-
Subtle afferent and efferent pupilary defects
tion in amblyopia are found in Chapter 6.)
Defective accommodation: increased latency, inaccu-
Reduced visual acuity is the best-known clinical
rate dynamk responses, fnconsistent responses,
feature of amblyopia. There does not appear to be a
poor sustaining abflity Deficient accommodativ
leveling or dip of acuity at the fovea, as once was
convergence with the
believed. In most cases of amblyopia, acuity still
amblyopic eye f ixating Deficient or
peaks at the fovea, as it does in the normal eye, but
absent disparity vergence
the resolution capacity of the peak is lower. In con-
trast, however, the resolution capacity of peripheral
visual form deprivation during early childhood. If
12 retinal regions in an amblyopic eye is approxi -
anisometropia, strabismus, or other causes of form mately the same as in the nonamblyopic eye. The
deprivation occur relatively late in life, amblyopia implication is that the foveal receptive field organi-
does not develop. If there is no mpedance to clear zation in amblyopia is coarser than normal, in part
retinal imagery or binocular coordination of the eyes, due to lack of development. In other words, ambly-
31
visual acuity develops fairly rapidly from the time of opia is fundamentally a defect of central visin.
birth. There is a rapid increase of visually evoked Reduced visual acuity is not the only visual df-
potential acuity to near-adult levis within 8 months icit found in amblyopia (Table 5-4). A large body of
of age, which actually reaches an adult level by 13 research data has accumulated that describes
28
months. The receptive field organization of foveal visual characteristics in various types of amblyo-
12
visin (retinal, lateral geniculate nucleus, and corti- pia. Cuiffreda et al. wrote an extensive, in-depth
cal) undergoes a poorly understood process of neural analysis of the literature. They regard amblyopia as
tuning to higher spatial frequencies of contours at all a developmental anomaly involving primarily
orientations in the environment. However, the con- those cortical mechanisms involved in form and
solidation of these neural processes takes consider- shape perception. There is insufficient evidence
able time, probably 5-7 years. A clinical study by supporting the concept of receptor amblyopia (i.e.,
29
Keech and Kutschke concluded that the upper age a fundamental defect n retinal rods and cones). A
limit for the development of amblyopia is 73 months defining defect in both strabismic and anisome-
(approximately 6 years). Anisometropia, constant tropic amblyopia is reduced photopic contrast sen-
unilateral strabismus, high refractive error, and visual sitivity for high spatial frequencies (i.e., fine detail),
form deprivation can all interrupt the normal process with little or no loss at low spatial frequencies (i.e.,
of acuity development and consolidation within this coarse forms). This loss of contrast detection for
time period. fine detail in central visin increases with the
severity of the amblyopia and appears to have a
neural basis rather than, for example, an ptica! or
oculomotor basis. In anisometropic amblyopia,
this dficit persists throughout the binocular visual
field of the amblyopic eye, which is consistent
Chapter 5 147
with retinal mage defocus. In strabismic amblyo- fixation s seen actually to be composed of micro-
pia, however, the dficits in contrast sensitivity are drifts from perfect fixation, corrective microsac -
often asymmetrically distributed across the visual cades, and physiologic tremor. The abnormal
field in a way consistent with the pattern of sup- component of microscopic eye movements n an
pression found in strabismics. amblyopic eye appears to be the microdrifts hav-
12 33
According to the review by Cuiffreda et al., ing an increased amplitude and velocity. Schor
34
amblyopia is also characterized by marked spatial and Flom proposed that there is an increased
uncertainty. The amblyopic eye has a relative inabil- "dead zone" for corrective saccades n amblyopia:
ity to judge position, width, and orientation of Because there s reduced detection of a fixation
detailed forms. In anisometropic amblyopia, the loss error, the amblyopic eye drifts from foveal fixation
n spatial judgment is consistent with the reduced farther and faster (due to increasing velocity with
resolution and contrast sensitivity of the amblyopic distance) than does a normal eye. Therefore, one
eye. In contrast, strabismic amblyopes show an extra component to reduced visual acuity in amblyopia
loss in positional acuity, often accompanied by might be the reduced and variable resolution of
monocular distortions (.e., contractions and expan- nonfoveal retinal points.
32
sions) of space perception. The reviewers sug- EF s considered to be an extrafoveal time-aver-
gested that this intrinsic cortical spatial distortion n aged position of fixation. Rarely does one find a
strabismic amblyopia may be due either to loss of perfectly steady EF pattern in strabismic amblyopia
neurons or to scrambling of signis secondary to the when fixation is attempted with the amblyopic eye.
abnormal binocular interactions found in constant In most cases of strabismic amblyopia, unsteady EF
developmental strabismus. One interesting implica- is the usual observation. It is also seen, unexpect-
tion of this concept is that there may be a causal edly, in some patients having solely anisometropic
relation among ARC, monocular distortions, and EF amblyopia. In cases of EF, patients believe they are
in strabismic amblyopia. looking directly at the target although they are, in
A survey of anatomic and physiologic studies of fact, fixating with an extrafoveal point or rea: The
the visual pathways of animis and humans with principal visual direction of the amblyopic eye (also
amblyopia ndicates markedly disturbed cortical called the straight-ahead direction) has shifted away
12
function. In anisometropic amblyopia, the spe- from the fovea. The monocular spatial distortions
cific cortical dysfunction appears to be related to found in strabismic amblyopic eyes and described
35
those neurons subserving contrast sensitivity. In by Bedel I and Flom may be the pathophysiologic
strabismic amblyopia, there is a dramatic loss of basis for an EF pattern. These monocular spatial dis-
cortical connections of the amblyopic eye. The lat- tortions occur only when both amblyopia and stra-
eral geniculate nucleus often shows shrinkage of bismus are present; they have not been found in
cells n layers connecting the amblyopic eye, a amblyopes without strabismus or in strabismics
36 37
defect believed to be secondary to the cortical without amblyopia. '
changes through retrograde degeneraron. Elec- Saccadic and pursuit eye movements of an
troretinographic studies suggest that retinal abnor- amblyopic eye are usually defective, as one might
malities are not a fundamental characteristic of suppose. In amblyopic eyes, three abnormalities of
amblyopic eyes. Amblyopia apparently results the saccadic system have been reported: (1) increased
from the effects of at least two mechanisms during latency, (2) reduced peak velocity, and (3) dysmetria
early visual development: cortical competition for (inaccuracy). The ncreased latency (slower reaction
connections from the two eyes and cortical inhibi- time) often exceeds 100% and s considered by
12
tion (suppression) when there is asymmetric binoc- Guffreda et al. to reflect a slowing in the sensory
ular input to cells. pathways that process visual nformation subse-
Besides the sensory dficits n visual acuity, con- quently used by the oculomotor system in generat-
trast sensitivity, and spatial temporal processing, an ing saccadic eye movements. Large horizontal and
amblyopic eye has several deficiencies in monocu- vertical saccades of an amblyopic eye are usually
lar eye movements, some of which are characteris- hypometric (undershoots), mltiple, and variable.
tic of the condition. One characteristic feature Also, in deep amblyopia, 20% of such eyes make
found in most amblyopic eyes is an unsteady fixa- saccades that are unequal in size; the amblyopic
tion pattern. Normal fixation appears steady only eye follows the dominant eye but not to the same
by gross nspection. W ith magnification, normal degree. These nonconjugancies (lack of exact comi-
148 Chapter 5
lance) often are larger in one direction than in its often depend on this evidence. Questioning should
opposite.38 Pursuit eye movements o an amblyopic relate to strabismic history, reractive history, and
eye often break down into a series o saccades, sug- social history.
gesting reduced and variable gain in the neurologic The time o onset of amblyopia oten coincides
control process. Consistent with these anomalies, with that o strabismus; thereore, it is vitally
the optokinetic nystagmus (OKN) responses o an important to know the age of onset o the strabis-
amblyopic eye often appear defective, because they mus. It generally ollows that the earlier the onset
are composed o both saccadic and pursuit compo- and the later the therapeutic intervention, the
nents. An asymmetry in the OKN responses may be deeper the amblyopia and the more difficult it is to
seen in strabismic amblyopia. For example, tempo- treat successully. Also, eccentric fixation is less
ralward stimulation of the amblyopic eye may show likely to develop i the onset is after the child's
a reduced response as compared with nasalward third birthday.
stimulation. The mode o onset o strabismus can influence
The triad responses of accommodation, pupillary the prognosis. A constant strabismus rom the
constriction, and accommodative convergence are onset is more likely than intermittent strabismus to
also affected in amblyopia. Both static and dynamic produce deeper amblyopia. The depth o amblyo-
accommodation demnstrate response abnormali- pia probably is related to both the duration and
ties. One would expect, thereore, that accommo- intensity o suppression, which would be greater in
dative vergence responses with a ixating amblyopic a constant deviation at all distances. Another
eye would be correspondingly reduced, and some important question regarding mode o onset is
research evidence supports this prediction.39 With concerned with eye laterality. That is, was the stra-
regard to dynamic accommodation, response abnor- bismus unilateral or alternating at onset? As a rule,
malities include increased latency, reduced gain, i the child alternates, the likelihood of amblyopia
increased response variability, and poor sustaining diminishes. Even in some esotropic cases that
ability.12 The site o the accommodative dysfunction appear to be unilateral at onset, a child may use a
seems to be in the sensory rather than the motor orm o alternation. Some esotropic infants and
controller. Besides the sensory dficit, accommoda- children learn to cross-ixate without any alterna-
tion responsiveness is reduced further by such ac- tion in the primary position o gaze. For example, a
tors as abnormal ixational eye movements, defective let eye with constant unilateral esotropa may be
contrast sensitivity, and EF. The deicient accommo- used to view objects in the right ield of gaze such
dative responses ound in amblyopia can usually that each eye would get adequate visual stimula-
be improved signiicantly with visin training. tion monocularly, and the development o amblyo-
There are oten subtle aerent pupillary deects pia would be prevented.
in many amblyopic eyes; response latencies may Information about previous treatment should be
be increased and amplitude decreased.12 Clinical thoroughly and careully sought. I occlusion was
testingwith a penlightcan, in many cases, indcate prescribed, the clinician should try to establish
an aferent deect, as seen with the swinging lash- whether the patient adhered aithully to the wear-
light test. There is evidence that these deects nor- ing schedule. Frequently, careful questioning reveis
malize with successul amblyopia therapy.40-41 that patching was done only as a token gesture. I
Fusional or disparity vergence oten is ound to extraocular muscle surgery was performed, com-
be deficient or absent in cases o amblyopia.39'42'43 plete information about the strabismic deviation
The deficient disparity vergence responses appear beore and after the operation should be obtained,
to be related to the depth and extent o suppres- i possible. The duration o amblyopia can be
sion associated with amblyopia and strabismus. assumed to be about the same as the length o time
Strabismic individuis having defective disparity the patient has had a constant unilateral strabis-
vergence requently substitute accommodative ver- mus. It is unlikely that amblyopia developed dur-
gence to shift their eyes to a new target position. ing the period when the strabismus was either
intermittent or alternating.
In determining the prognosis for successul treat-
Case History ment o amblyopia, the two most important factors
An in-depth case history should be obtained rom rom the case history are the best estmate of the
every amblyopic patient. Diagnostic conclusions time of onset and the time at which appropriate
Chapter 5 149
TABLE 5-5. Prognostic Factors in Amblyopa Learned the onset of amblyopia, the better and faster s the
from Case History outcome. The importance of early detection and
treatment of amblyopia cannot be overempha-
sized. We recommend that all children have a
Ageat complete eye examination within the first year of
Onset of ufe to check for the host of visual conditions that
can affect visual development.
Amblyopia Age at Irtitiattofl
(yrs) of Therapy {yrs) Prognosis
iirth - t 1 Good
Birth-1 2 Fair te good
Visual Acuity Testing
Birth-1 3-4 Fair
Departure from customary visual acuity measuring
Brth-1 5-6 Fair to poor s often required when an amblyopic eye is being
Birth-1 >7 Poor
tested. This s because of the wide variation of
1-2 2-3 Good responses when an ordinary chart of Snellen opto-
1-2 4-5 Fair to good type s employed.
1-2 6 Fatr
1-2 2:7 Fair to poor Snellen Charts
2-4 4-6 Good Snellen tests have remained essentially the same
2-4 7 Fair to good since Hermn Snellen devised the first chart in
1862 (see examples n Figure 5-8). A Snellen chart
s usually adequate for testing the acuity of nonam-
treatment for amblyopia began. Table 5-5 summa- blyopic eyes, but it is not designed for reliable
rizes theoretical prognostic expectations based on i nterpretation of visual acuity n amblyopia.
these factors, which reflect our clinical experience A standard ciinical criterion for assessing the acu-
n working with patients. The later the onset of ity threshold is that at least 50% of the letters n a
amblyopia, the less profound s the loss of acuity particular Une on a Snellen chart must be identified
during the critical period of acuity development. correctly. There s usually no probiem in determin-
The earlier the appropriate treatment begins after ing this level n a nonamblyopic eye. A myopic
E DNUP
LO e T E V B C L
(E)
Using Landolt Cs and movable interacting bars,
E m E m ui
3 OO O E
iii c E o a
U N R Y E E OC O 3
mmm E iii
HNERU
FIGURE 5-12Psychometric chart of Flom.
H D V Z F
U F Z R E type spacing and flexibility of use at nonstandard
RHDNU distances makes the Bailey-Lovie chart particularly
E UFH P suited for amblyopia assessment. Several different
F N P U V optotype versions of the chart are available to min-
PEUFH imize memorization of letters on repeated testing.
FVZEP
Psychometric Charts
The psychometric chart, also referred to as the S-
chart, was designed by Flom 46 and takes the
crowding phenomenon into account as well as the
problem of an indefinite acuity threshold in ambly-
opes. The S-chart slide series consists of 21 individ-
ual 35-mm projected slides. Each slide contains
eight Landolt Cs of a particular size for which the
FIGURE 5-11Bailey-Lovie chart. (Courtesy of the School of Optom- "gap" randomly appears in one of four positions:
etry, University of California, Berkeley.)
up, down, left, or right (Figure 5-12). The slides
come n graduated sizes from 20/277 to 20/9,
ters in the middle of a line are more frequently descending n 5% visual efficiency ncrements (2O/
misread than those at the ends of the line, (3) let- 20 = 100% efficiency; 20/200 = 20%). (See Visual
ters are transposed n position, and (4) solated let- Acuity and Visual Efficiency in Appendix F.) At
ter acuity s better by one or two Unes than s each of the 21 acuity levis, the interletter spacing
single-line or full-chart acuity. is equal to the letter size, and each letter is sur-
rounded by an equal number of contours. There-
Bailey-Lovie Chart fore, the contour interaction effects on each slide
The Bailey-Lovie visual acuity chart (a cardboard, are constant. At each acuity level, the number of
free-standing chart) was designed specifically for correct responses s recorded on the test form, with
low-vision patients, but t can be used efficiently eight being the mximum number of correct calis.
also for testing many amblyopic patients (Figure The visual acuity threshold for a particular patient s
5-11). On this chart, the number of letters on each determined by psychometric analysis. After the
line (five) and letter spacing are consistent. This is a series s completed, a best-fit sigmoid curve is
distinct improvement over the traditional Snellen drawn on a chart (Figure 5-13a) representing the
chart. Many times t is desirable to test a patient at data. (Figure 5-13b Ilstrales the S-chart visual acu-
closer distances than 20 ft (6 m); the acuity may be ity plot of a normal and an amblyopic eye.) Note
worse than 20/200 (6/60), or the patient may be an that the ordinate of the recording graph represents
uncooperative child or an older patient who is a the acuity threshold and the abscissa, the number of
malingerer. The steps in letter size are based on a correct responses. The intersection of the sigmoid
logarithmic scale of the mnimum angle of resolu- curve with the abscissa valu of 5 determines the
tion or logMAR. This scale allows for easy determi- visual acuity threshold valu. The criterion for acu-
nation of Snellen-equivalent visual acuity at testing ity is the 50% level of correct responses. Intuitively,
distances other than 6 m. This consistency of opto- four of eight correct responses would represent the
152 Chapter 5
Dame OD Date
?p
Eocentricity
Duracin w/o Rx
A
B !
X. 7 L D R D U D R U 110
2. s D U L D R U L O
-+F FIGURE 5-13a. Custom-made
3. z R L U L D R 0 L recording chart for psychometric
visual acuity testing. The first col-
4. I6 0 L D R L R D R umn (1, 2, 3, etc.) s the slide num-
5. 3J L D R U L D U D ber. In the second column (A), the
numbers (9, 15, 20, etc.) represent
20/9, 20/15, 20/20, and so on,
6. 3 D U L D R U L
respectively. The next series of col-
1 . "5 U R L R U L D R umns indcate the correct response
8. 5J U L D R L R D R (D = down; L = left; R = right; U =
up). The last column (B; 110, 105,
9. to L D R U L D U D 100, etc.) represents percentage of
visual efficiency. b. Graphical
0. 68 R 0 D U R U L D results for an amblyopic patient
who had reduced visin in the right
1. TI 0 R L R U L D R eye (lower curve) and normal visin
2. 1 O R U L D L R L in the left eye (upper curve). Large
charts are used initially to ensure
3. 7 I, D R D U D R U that two consecutivo triis are all
correct (i.e., eight of eight calis).
4. 15 u R L R U L 0 R
Target size s reduced n 5% visual
5. 112 D U L D R D L U efficiency steps until two or fewer
R
correct calis are made for two con-
6. >' D U L D t, R L
secutive charts. The best-fit curve is
drawn for the plotted data. Visual
7. 155 R U D U R U L O
acuity s determined by the place at
8. 1'5 L D R U L D U D which the curve crosses the line
representing five of eight correct
9. 200 R L U L D R D L calis. In this example, the left eye
0. ' U L D R L R D R has 20/9 acuity (visual efficiency of
.tttt
110%), and the right eye has acuity
1 . " D R U L D L R L between 20/109 and 20/122, with
visual efficiency of 42%.
50% level, but this does not take guessing into the orientation of each C, even if this
account. Merely by guessing, the patient has a one requires strictly guessing; this is a forced-
in four chance of a correct cali for each Landolt C, choice procedure. On the recording form,
which is why five of eight represents the adjusted the correct orientations are usted. The
50% level. examiner indicates each correct cali with a
Testing and recording of visual acuity by means slash mark. For each incorrect cali, the
of the S-chart proceeds as follows: examiner indicates the patient's response
with a subscript (see Figure 5-13b).
1. The patient wears CAMP lenses during test 5. The examiner tests the patient using slides
ing in a darkened room. of decreasing size until only two or fewer
2. The nonamblyopic eye is tested first. correct calis are consistently made, indicat-
3. The examiner begins with sufficiently large- ing that the patient is merely guessing.
lettered sudes so that the patient properly 6. The number of correct calis is plotted on the
identifies all Landolt Cs in the correct orien- adjacent graph. The best-fit sigmoid curve is
tations. then drawn on the graph by visual inspec-
4. The patient is asked to begin making calis tion of the data points (see Figure 5-13b).
starting with the upper left-hand Cand pro- 7'. Steps 1-6 are repeated for the amblyopic eye.
ceeding in a clockwise direction for the 8. The acuity thresholds for the normal and
remaining seven Cs. The patient must cali amblyopic eyes are indicated by the nter-
Chapter 5 153
52 SO 6 S
D
R
U
L
L
U
D
L
R
D
U
R
L
U
U
L
05
100
-l-i-
H-i '
'
S^^
-uf JL_|_L 1J_J
i.
3
17 1 7 1 0 9 1 2 U L D R L R D R 9S
2 1 > 7 1 55I 7 L D R U L D U D so
4_H--4ji_ r_.-
i.: .- -U-rJ ------ L
5 2 0 0 2 32 Z D U L D R U L U 5
5
7T U R L R U L D R o
6 " T """'"f -H'I~ "~
U L D H L R D R 75
7
R U D U R U L D 15
L D^ Ly Rt J 55
X X X DU OL X X u t - so
u. X X X u X D X <>\
* n /C
t^ i*O*
x TI
W'
Vf JO\J yf
Q
Ju
JK.
JO JO Jo
tu
X X
X X
X X
X X
X X
X X
X X
X X
X30 XX"S
T/ Vf
tf i, _!_[. r1 j.| ;--j-j ------
R
. rf Mf .1!;
= S ^~
l( 1$
X X
' :.! 1
X X
2S
X -i ------------------ L 4.,
X X
.i
X X
X X f... -
2
X X
- u . ^ . _ ^ _uLf-_.
- . _-U
^.
---^-. ----------------
^
^, TZT trrt
___ ._
- ^^^it
1%
g
.11
D R U L D L R L ll TP : i ' i jH ----- L- r- -
? n-
siS
section of the sigmoid curve and the
abscissa valu of five correct responses
(50% threshold corrected for guessing).
Davidson and Eskridge,47 to allow ease of use
of this test with young children, modified the S-
chart test by removing the Landolt Cs but leaving
eight fs (Figure 5-14). Less detall is intended to be
less confusing. They reduced the interletter spac-
ing to one-half the letter size to increase the effect
of contour interaction as compared with the S-
chart, which has an nterletter spacing equal to the
letter size. They reported this test to be reliable n
the assessment of visual acuity. It is used n essen-
tially the same way as is the S-chart. A convenient
hand-held series of S-charts of this design was
devised by Dr. Michael Wesson, University of Ala-
bama, School of Optometry, Birmingham. (This
test s available from the Optometric Extensin
Program Foundation, Inc. [see Appendix J for con-
tact information].)
assessment of visual acuity can also be used for does indeed resolve a particular spatial frequency
amblyopia screening for infants and children younger grating. Usually, only monocular testing is under-
than 2 years, n whom visual acuity charts and card taken using this technique, which usually works well
sets are inappropriate. The examiner simply observes with nfants younger than 1 year, because they
the infant's behavior when one of the nfant's eyes is innately prefer to look at detail. Older children, how-
covered or patched as compared with the behavior ever, need more interesting targets or operant condi-
when the other eye is occluded. For example, if a tioning rewards to make reliable responses. TheTeller
child consistently objects to having one eye occluded Preferential Looking Cardsa hand-held series of
as opposed to the other, unilateral visual impairment cards designed for clinical use or other similar tests
is suspected. If the child's reaching behavior s iess are available (Figure 5-19).
accurate with one eye patched as compared with the OKN has been used to establish visual acuity
other, impairment s again suggested. thresholds n infants, but its validity s question-
Preferental looking methods for visual acuity able. However, directional asymmetries to OKN
threshold determination offer a means by which to stimulation have been reported n patients having
study or test behavioral visual acuity development of infantile strabismus or amblyopia. If visual devel-
the infant. For these techniques, the examiner opment proceeds normally, each eye monocularly
exposes two targets, side by side, to an infant. One shows equal amplitude responses to nasalward and
target is a spatial frequency grating of a particular temporalward OKN drum rotation by approxi-
acuity level and the other is a blank gray field that has mately 6 months of age. If the infant develops
the same average luminance as the grating. Infants amblyopia or strabismus, responses are typically
from the time of birth prefer to look at a pattern rather Iess vigorous (i.e., lower amplitude and fre -
than at a blank field, if they can resolve the pattern. quency) when the striped stimuli are moving in a
On repeated presentaron of the targets, in random temporal direction as compared with a nasal
48
left-nght order, the examiner watches the patient's direction. Schor and Levi investigated this phe-
eyes and judges whether the infant sees the grating. nomenon and suggested that the asymmetric
This s done by observing which target the infant OKN was due to incomplete development of bin-
views more frequently. An 80% correct "looking" cri- ocular visin, which may explain why some
terion often s used to indcate whether the infant patients show OKN asymmetry of the nonambly-
Chapter 5 157
O
RCURE 5-18Lighthouse sym- 20 20 20
bob for visual acuity testing. 50 50 SO
topic as well as the amblyopic eye. However, This observation of OKN asymmetry can be
there does not seem to be a direct relation used clinically to screen for ambiyopia or stra-
Ibetween the degree of OKN asymmetry and the bismus in infants and young children. One eye is
[depth of the ambiyopia, although deeply occiuded while the other is tested using a striped
ambly-I opic eyes tend to exhibit increased drum rotating at a slow frequency of 8-10 revo-
asymmetry.12
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.
Interferometry
The interferometer s a useful instrument for evaluat-
ng the visual acuity of an amblyopic patient. It uses
the principie of nterference fringes, as with a lser, 20/160
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 FIGURE 5-23Sustained visually evoked potentials graph for visual
the grating over a large range, each setting corre- acuity assessment. Responses indcate visual acuity of 20/80 for the
right eye (oculus dexter [O.D.]) and 20/20 for the left eye (oculus sin-
sponding to Snellen visual acuity. The advantage of ister [O.S.]), judging from amplitude comparisons.
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 determina-
tion s quick and s obtained by asking the patient to from Bernell Corporation; see Suppliers and Equip-
dentify the orientation of the grating (vertical, hori- ment n Appendix J) (Figure 5-24). Interferometers
zontal, or diagonal) at the various acuity settings. typically use four-choice targets (Figure 5-25).
The acuity determination s independent of eccen-
tric or unsteady fixation, similar to the VEP. There- Fixation Evaluation
fore, in cases of amblyopia, the acuity estmate can Fixation s normal when the center of the fovea s
be useful n making a diagnosis and, possibly, in used for fixation and when fixation is steady. If any
estimating the prognosis for success of therapy. other rea of the retina is used (eccentric fixation),
52
Selenow et al. compared pretherapy interfer- or if there is significant unsteadiness, fixation is con-
ometry visual acuity with pre- and post-therapy sidered to be abnormal. Eccentric fixation, then, is
optotype measures of visual acuity in a group of 37 considered to be an abnormality of monocular fixa-
patients with amblyopia. They found that, n most tion in which the time-averaged position of the
cases, the pretherapy interferometry acuity and the fovea s off the fixation target. Unsteadiness refers to
post-training Snellen acuity were in cise agree- the presence of nystagmuslike oscillations (usually
ment. Ninety-percent were with i n two acuity Unes irregular flicks and drifts) of the affected eye. These
of each other and, n 75%, they were within one oscillations are often noticeable on careful direct
line. If further nvestigations support these impres- observation but are more easily observed during
sive results, interferometry may prove to be an visuoscopy. An eye with 20/20 (6/6) or better visual
important prognostic tool n the assessment of acuity necessarily has central fixation that s rela-
amblyopia. A popular clinical nstrument, for tively steady, whereas an eye with poor visual acuity
example, s the SITE IRAS Interferometer (available may have eccentric or unsteady fixation.
Chapter 5
b.
HAIDINGER'S BRUSHES (H.B.)
(PERCEIVED BY PATIENT).
PATIENT USES
POINTER TO INDCATE
WHERE HE PERCEIVES
THE H.B.
usually associated with the eccentric point, not the Refraction Procedures
[fawea. The brush will appear, when it s perceived, Subjective refractive techniques are usually unreli-
i cff to one side of the fixation target on the MITT. able when testing an ambiyopic eye, due to the
When an ambiyopic patient is experiencing dif - abnormal fixation pattern and the deficient spatial
fculty in observing the brush, several techniques resolution. Consequently, cycloplegic retinoscopy
may help to elicit its perception: First, the appear- is often necessary for determining the refractive
ance of the Haidinger brush can be demonstrated error. We generally use one drop of 1% cyclopen-
using the patient's nonamblyopic eye, for which tolate preceded by a drop of 0.5% proparacaine.
;ie entoptic image should be relatively easy to In most patients, the cycloplegic effect is suffi-
appreciate. Second, the background room illumi- ciently strong to reveal the full amount of hypero-
nation can be lowered to increase the contrast of pia, if it exists. We prefer not to rely completely on
me MITT screen, and double (two) cobalt-blue fil- a phoropter in cases of ambiyopia (or strabismus).
teis can be used over the ambiyopic eye, occlud- It is easier to monitor the fixation by directly view-
ing the nonamblyopic eye, to intensify the ing the patient. The refractive error is determined
perception of Haidinger's brush. A third technique with trial-case lenses or a lens bar. To ensure accu-
involves placing a high-plus trial-case lens (e.g., -i- racy, care must be taken that the retinoscopic
lO D) in front of the cobalt filter, which will blur beam on the ambiyopic eye is directly on axis. The
out all extraneous contours and shadows but leave correct visual axis can be estimated with a penlight
ihe entoptic image unaffected. Finally, to confirm by moving to a lateral position at which angle til
n
mat the perceived image is indeed the Haidinger kappa of the ambiyopic eye equals that of the nor-
brush, a piece of cellophane or plstic wrap can mal eye. In cases of ambiyopia associated with
be inserted before the ambiyopic eye to determine esotropa, on-axis retinoscopy is easily accom-
whether the direction of brush rotation is reversed. plished by scoping the ambiyopic eye from the
The cellophane acts as a quarter-wave pate and opposite side (e.g., n a case of a right esotropic
should reverse the perceived direction of rotation ambiyopic eye, scoping from the patient's left
o the entoptic image. side). In cases of anisometropic or strabismic
Besides establishing macular ntegrity, the Haid- ambiyopia, correction of the full refractive error
inger brush can be used to evalate the fixation pat- usually is prescribed even when a patch s to be
tem of an ambiyopic eye. Most characteristics of the worn. Undercorrecting hyperopia can be a mis -
fixation pattern that are observed by visuoscopy can take, because the accommodative responses of an
ako be assessed using the brush if the patient is a reli- ambiyopic eye are usually deficient.
able observer. The patient is instructed to fixate a
suprathreshold target on the MITT at exactly a 40-cm
distance from the nstrument. After the correct per- Eye Disease Evaluation
ception of the entoptic image s established, the fol- Before the diagnosis of ambiyopia is made, the cli-
lowing assessment of fixation can be made: Is there nician must investgate the possibilty that ocular
central or eccentric fixation? If there is EF, what is the pathology may be the direct cause of the reduction
direction and magnitude? (Note: At a 40-cm fixation in visual acuity. It s prudent to be suspicious of
distance, 4-mm lateral displacement on the screen eye disease or pathology affecting the visual path-
A ways in all cases of unexplaned reduction of
represents 1 .) Is there steady or unsteady fixation? If
there is unsteady fixation, what are the amplitude visual acuity, even in cases associated with ani-
and type of oscillations? Is the fovea included within sometropia and strabismus; it is possible for
the range of unsteadiness? Is there faulty localizaron organic eye disease to coexist with ambiyopia. The
associated with EF or s the patient eccentrically following procedures provide the basis for making
viewing? a clinical distinction between a pathologic loss of
Visuoscopy, of course, has a major advantage acuity and nonorganic ambiyopia.
over the MITT as an assessment technique because
t is objective; however, the MITT can be immedi- Ophthalmoscopy
ately employed in the remediation of faulty fixa- A dilated fundus examination may be necessary
tion associated with ambiyopia. Both instruments, for careful inspection of the macular and foveal
the visuoscope and the MITT, are important and regions of the ambiyopic eye. However, detection
useful in the management of EF. of subtle retinal lesions can be difficult. Besides
164 Chapter 5
using direct and indirect ophthalmoscopy to recoverable; ihis more oplimislic view is based
examine an amblyopic eye, we recommend a on his findings Ihal some nonorganic cases of
careful slit-lamp inspection of the macula and deep amblyopia apparently exhibited an absoluto
fovea using higln magnification (e.g., a 60- or 90- cenlral scoloma.
D lens).
Neutral-Density Filters
Visual Fields Ammann55 proposed Ihal differenlial diagnosis of
Automated visual field testing is usually unsuccess- organic (pathologic acuity loss) and developmen-
ful or unreliable due to the poor fixation responses lal amblyopia is possible by comparing ihe visual
of an amblyopic eye. Ordinary tangent screen field acuity measured under normal versus reduced illu-
testing has some advantages over the automated minalion. There is an expected decrease of visual
techniques. Unsteady fixation of the amblyopic acuily when larget illumination is reduced for bolh
eye can be reduced if no central fixation target is Ihe normal and ihe amblyopic eye. Visual acuily
used. As an allernalive, four strips of masking tape normally decreases under mesopic and scolopic
or paper can be applied to the tangent screen at- conditions. However, if the cause of acuity loss is
ine 3-, 6-, 9-, and 12-o'clock positions approxi- pathologic (e.g., macular degeneraron, optic alro-
mately 10 degrees away from the cenler of ihe phy, cenlral palhway lesin), Ihe decrease in visual
screen; ihis pattern indcales a virtual fixalion acuily wilh decreased illuminalion is sudden and
poinl. The palient holds the amblyopic eye sleady dramalic.
on ihe virtual point at which the four lines would Caloroso and Flom 56 demonslrated that at
theoretically inlersect; then ihe field lesting of the essenlially all luminance levis, visual acuity in
blind spol, periphery, and cenlral reas proceeds Ihe funclional amblyopic eye was less Ihan that of
in the usual manner. Testing wilh a 1- or 2-mm Ihe normal eye. Al Ihe lowesl levis of luminance,
while target at 1 m is generally sufficient lo deter- however, il was approximalely equal. In contradis-
mine whelher a scoloma exisls. During this proce- tinction to funclional amblyopia, von Noorden
dure, the patienl should wear spectacles, contact and Burian57 convincingly showed Ihal in cases of
lenses, or trial-case lenses to correct fully any sig- macular organic lesions, visual acuily dropped
nificanl refraclive error. The visual field of ihe precipilously as illuminalion decreased, ihus con-
amblyopic eye is compared wilh that of the normal firming Ammann's observalions.
eye. Neulral-densily filler lesling can be used clini-
Amsler grid testing for central field defects is cally when a palienl presenls wilh unexplained
also recommended. As in langenl screen lesling, monocular reduced acuily and a differenlial
ihe visual fields of ihe two eyes are compared for diagnosis is needed. Eilher a 2.0- or 3.0-log unil
consistency. For lesling an amblyopic eye, we neulral-densily filler, such as a Kodak Wratlen
recommend Ihal a +2.50-D nearpoint add (a trial- Filler 96, should be used. We recommend mea-
case lens) be used along with any needed spectacle suring Ihe visual acuily of each eye under normal
correclion, because monocular accommodalion pholopic room-lighting conditions by means of
of an amblyopic eye is usually deficienl. Even if an S-charl. If a Snellen charl mus be used, Ihe
ihere is significant unsteady EF, ihe fovea will acuity thresholds should be converled to the
usually fall somewhere on the grid pattern and a Snell-Sterling visual efficiency scale (e.g., 20/20
central visual field defecl, if il exisls, may be = 100%; 20/50 = 76%). The palienl's eyes Ihen
noliced by ihe patient. are parlially dark-adapted (for approximalely 5
Schapero17 believes ihat deleclion of a cenlral minutes) lo a mesopic level. The appropriale
absoluto scoloma (no lighl perceplion wilhin ihe neulral-densily filler is placed over Ihe projec-
scotomatous rea) indcales an organic lesin or lor's objective lens, and the poorer eye is
amblyopia wilh an organic componenl and ihat occluded while Ihe visual acuily of Ihe beller eye
the prognosis for allaining beller acuily is limiled is quickly remeasured. Swilching the occluder,
by the potenlial acuily of Ihe retina! rea sur- Ihe clinician ihen determines Ihe acuity thresh-
rounding the absoluto scoloma. In conlrasl, old of Ihe poorer eye. Under mesopic condilions,
Irvine 54 reporled Ihal a relalive central scoloma the visual acuity of the better eye may have
(depressed sensilivily) is an indicalion of a func- decreased from 20/20 lo 20/40, approximalely a
lional reduction of acuity Ihal is polentially 15% reduclion in Snell-Slerling visual efficiency,
Chapter 5 165
for example. An organic lesin would be sus- functional improvement is good. Useless patching
pected f the visual acuity of the poorer eye is to be avoided.
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 macu- Screening for Ambiyopia
lar pathway lesions as compared with functional Ambiyopia s one of the leading causes of visin loss
ambiyopia. If the poorer eye, however, showed and monocular blindness and, because t develops in
only a 20% or lesser decrease in visual efficiency the early years, it affects an individual for life. The ear-
with the neutral-density filter, functional ambiyo- lier ambiyopia s identified, the more successfully it is
pia would be indicated. (See Appendix F for con- managed. One epidemiologic study found a 1%
versin scales.) prevalence of ambiyopia n 8-year-old children who
had been screened in infancy but a 2.5% prevalence
Tesis of Retinal Function in those children not previously screened.58The chal-
Two other tests may be helpful n making the dis- lenge is to find screening methods that are valid in
tinction between a pathologic reduction of acuity early childhood, are time- and cost-effective, and are
and functional ambiyopia. These are monocular easy to implement.
color visin and electroretinography. Several dis- One of the simplest procedures to apply in
eases of the retina and optic nerve result in subtle infants s for the clinician to watch for avoidance
monocular color visin defects. Retinal disease behavior when each eye s occluded n turn. Con-
tends to produce subtle blue-yellow defects, sistent avoidance when covering one eye s highly
whereas acquired optic atrophy often results n sub- suggestive of unilateral visin impairment. If there
tle red-green defects. Monocular color visin can s strabismus and a child can hold fixation with
be tested n most children of at least 10 years of age either eye or can freely altrnate fixation, then the
using the Farnsworth panel D-15 test. However, a patient usually does not have ambiyopia; n con-
good blue-yellow differential diagnostic test for trast, those who hold fixation with only a preferred
younger children may not be available. Using the eye tend to be amblyopic. This method should be
Farnsworth test, the color visin responses of each part of every pediatric health examination.59
eye are inspected for differences that ordinarily are A more reliable procedure is for a visin specialist
not found. If a defect s found with this test, it repre- to check for the presence of a strabismus using the
sents a strong defect. The desaturated panel D-15 Hirschberg test or the cover test, followed by objec-
may be necessary to pick up the initial signs of color tive measuring of the refractive error by retinoscopy.
visin defects attributable to eye disease. This short screening procedure is effective but expen-
Another test of retinal function that may help in sive, because a doctor's time and skills are involved.
the differential diagnosis is the electroretinogram The most promising procedure on the horizon
(ERG). Although the research literature is very seems to be photorefraction. Several competing pho-
mixed, consistent differences are not apparent in toscreening models are on the market, and research
the ERG responses between normal and amblyopic to perfect the technology contines at a fast pace.60'61
eyes.2 If abnormal ERG responses or significant dif- Photographs of an nfant's or youngster's eyes are
ferences between the eyes are found, the condition taken so that the Brckner reflexes can be analyzed.
is unlikely to be functional ambiyopia. For exam- These photographs do not identify ambiyopia directly
ple, the pattern ERG s abnormal n cases of Star- but answer the question: Does this child have any
gardt's macular dystrophy (a juvenile rod-cone condition that can lead to ambiyopia? The reflexes
dystrophy), which may be confused with ambiyo- reveal the presence of excessive refractive error, ani-
pia during its early stages. The ERG procedure usu- sometropia, strabismus, cataracts and other
ally requires referral to a visual functions testing media opacities, and even congenital glaucoma
clinic at a medical or optometric center, as most (Figure 5-29).62 This procedure has proven to be sen-
primary care doctors do not have the relatively sitive to identifying a strabismus as small as 10A.63 It is
expensive instruments used for this evaluation. The quick, easy, portable, and totally noninvasive. The
expense of this test often is justified if there is a child can sit on a parent's lap n dim illumination
reasonable suspicion of retinal disease, because with the camera from 1 to 6 m away.64 The process of
patching of the sound eye can be a very frustrating photorefraction, ncluding nterpretation of the pho-
procedure for a patient even when the chance of tographs, can be taught to lay personnel. Efforts are
166 Chapter 5
FIGURE 5-29Examples of
conditions detected with the
PhotoScreener, a photorefractive
instrument that shows how vari-
ous anomalies are dentified.
(Courtesy of Marco Ophthalmic,
Jacksonville, FL.)
being made to have the photographs analyzed by mus of early onset. It is defined as the binocular
computer programs, which should further cut costs. condition in which the two foveas and other
As this technology advances, massive screening homologous retinal loci do not correspond to
projects of infants, toddlers, and preschool children each other in regard to directional vales: The pri-
should be feasible, valid, and cost-effective for the mary visual direction in the deviating eye has
early identification of amblyopia and other major shifted to a nonfoveal location to be in accord
conditions that can cause visin impairment. with that of the fixating eye. This shift of direc-
tional valu allows at least some sensory integra-
tion of the two eyes, so that the strabismic
individual is not "monocular." Although the corre-
ANOMALOUS CORRESPONDENCE spondence actually takes place in the cortex of
Anomalous correspondence s a sensory defense the occipital lobe, clinicians refer to retinal corre-
mechanism against diplopia that preserves rudi- spondence because the retinas are the reference
mentary binocular visin in response to a strabis- locations for angular measurements. Consequently,
Chapter 5 167
A-0
V. FOVEA AND
POINT "a"
COINCIDENT
PAT1ENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
ing eye corresponds with point a n the deviating cates S = O (or a valu cise to zero) when a stra-
eye when there s ARC. Point a s strictly funo bismic deviation s present. HARC is suspected
tional; there s no retinal landmark as there is for n such cases. An example of HARC s as follows
point f. (see Figure 5-32):
The type of ARC occurring most frequently in H = 25A S = 0A /4 =
natural seeing conditions is harmonious ARC 25A-0A
(HARC). An example of this is illustrated in Fig-
ure 5-32, n which S equals 0A and A has the
same magnitude as H. Such strabismic patients Not all cases of ARC are harmonious. Assume
often give orthophoric responses during routine that a patient has an esotropa of the right eye of
phorometry. This is because point a is in the same 25A and that S equals 12A (as measured by subjec-
location as point zero. The fovea of the fixating tive tests such as the dissociated red lens test). The
left eye in this example corresponds to point a of fact that H and S are different suggests ARC. Figure
the right eye, which happens to be coincident 5-33 Ilstrales this example by depicting points f,
with point zero, the target point. Clinicians, a, and zero (also called point O in the deviating
therefore, should be on guard f phorometry indi- eye). This example represents a case of unharmoni-
Chapter 5 169
ARC. If point a s at the target point (zero), there is patients can be said to have peripheral fusin (Fig-
HARC; if between the fovea and the point zero, ure 5-37). The nonstrabismic's horopter goes
there s UNHARC; f nasal to point zero, paradoxi- through the point of fixation. When an ntermittent
cal ARC type one; and f temporal to the fovea, esotrope with NRC lapses into a strabismic devia-
then paradoxical ARC type two. See Table 5-7 to tion, the horopter shifts from the plae of the target
review the relations among angles H, 5, and A that to a point where the visual axes cross (the centra-
serve to classify types of correspondence. tion 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
Characteristics there s esotropa with ARC, the horopter beyond
Horopter n Anomalous the rea between the visual axes remains n the
Retinal Correspondence plae of the target of regard, and the world
Flom65 demonstrated that the dentical visual appears fused even though there may be some
direction horopter in strabismic patients having central suppression (see Figure 5-37c). This s a
ARC has an irregular shape that may help to very convenient adaptation for the strabismic indi-
explain many of the characteristics of the condi- vidual, because diplopia s eliminated. Peripheral
tion. The peripheral horopter n ARC cases was stereopsis may be present if angle H is small (see
similar in shape and location to that n nonstrabis- Figure 5-3 7d) and fusional vergence eye move-
mic patients with NRC and, in that sense, these ments can still occur.
Chapter 5 171
POINT '
PATIENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
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 retinal 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 cross-
ng 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 eva- new coupling of noncorrespondmg cortical ele-
sin,"69 patients needing psychotherapy,70 intracta- ments. Visually mature individuis, older than 6
ble diplopia,71 and aniseikonia.72 Not much has years or so, who acquire a strabismus later in life are
been published on this condition, and the mecha- almost always incapable of developing ARC.
nism has been uncertain. According to Burian,75 "ARC is acquired by usage ...
We believe this condition is almost always asso- the acquisition of an anomalous correspondence
ciated with ARC. An inspection of the horopter in represents an adaptation of the sensory apparatus of
ARC gives a clue to the nature of this binocular the eyes to the abnormal position of the eyes." The
anomaly. Aniseikonia, indeed, appears to be a fac- earlier the onset of the strabismus and the longer an
tor. The fovea of the fixating eye seems to be asso- individual "practices" ARC (a learned response), the
ciated with many points in the strabismic eye and deeper the ARC adaptation is established. This view
vice versa. For example, as shown in Figure 5-37c, has come to be known as the adaptation theory of
it is as though the fovea of the left eye is associated ARC. This theory would predict that ARC would tend
with a series of points between points zero (same to be found in early-onset, constant, comitant stra-
location as point a in HARC) and f of the right eye, bismus and less often in late-onset, intermittent, or
creating an intolerable magnification effect. Flom65 noncomitant strabismus. Substantial clinical evi-
explained horror fusionis in subjects with esotropa dence confirms this prediction.
and ARC on the basis of nonuniform, relative dis- Morgan76 proposed that ARC is a motor phenom-enon
tributions of corresponding retinal points (irregu- (rather than merely a sensory adaptation) and
larly shaped horopter). He explained the horror stated, "Thus anomalous correspondence might
fusionis movement of the images when superimpo- depend not on a sensory adaptation to a squint but
sition is attempted, as in the Synoptophore: A sud- rather on whether the basic underlying innerva-
den movement occurs when the target of the tional pattern to the extraocular muscles was one
deviating eye is moved across a limb of the notch which registered itself in consciousness as altering
of the horopter; it is not due to any eye move- egocentric direction, or whether the pattern was
ments. Flom65 explained, "This jumping phenome- one which was 'nonregistered' in consciousness as.
non is commonly observed by strabismics with altering egocentric direction." A nonregistered
ARC when viewing constantly illuminated first- innervation would imply NRC, whereas a registered
degree targets, one of which is moved toward the pattern would imply ARC. This notion is called the
other to obtain superimposition." motor theory of ARC. It implies that at the time of
strabismus onset, the moment the eye turns, an
Etiology ofAnomalous abnormal neural circuit allows the change in ver-
Retinal Correspondence gence eye position to be "registered" in the percep-
The neurophysiologic basis for ARC is unknown, but tual mechanism subserving visual direction. Kerr77
most authorities assume that the visual cortex medi- suggested that the fundamental error in the neural
ates 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
circuitry is a disorder n the disparity detection two or more etiologies for ARC, and a complete
mechanism, either on the convergent side, yielding description of the condition will require appreciat-
esotropa with ARC, or on the divergent side, result- ing at least both developmental sensory and reflex
ing in exotropia with ARC. motor aspects. The clinical challenge may be to
Ordinarily, versin eye movements are "regis- determine which mechanism is primarily responsi-
tered" and vergences are not, but an abnormal ble for ARC n a particular patient. Vision therapy
reflex, possibly genetically determined, links ver- related to the cause or causes can then be more
gence to the perceptual apparatus. ARC localiza- appropriately prescribed for efficacious treatment.
tion s, therefore, immediate and complete, all or
none. This view dispenses with the concepts of Depth ofAnomalous Ret
depth, learning, and adaptation and suggests that nal Correspondence
ARC is a neural reflex possibly mediated by the Those who espouse the adaptation theory of ARC
neurology responsible for the well-documented believe it s clinically useful to evalate the depth
phenomenon of ARC covariaton. Hallden78 dem- of the condition. Testing the depth of ARC is analo-
onstrated that strabismic patients with ARC have gous to testing the intensity of suppression; if test-
some daily variation n their angle of deviation (H) ing conditions are very unnatural, suppression is
and that the angle of anomaly increases and not likely to be found. Burian75 promoted the con-
decreass n tndem with t. Covarying ARC also cept that ARC is an acquired sensory adaptation to
has been reported n some patients with A and V a motor deviation and that this adaptation may be
patterns in which the strabismic angle changes n either deep or shallow. This may explain the more
up- and down-gaze.79 Correspondence can also be frequent clinical finding of ARC on Bagolini stri-
demonstrated to change synchronously with fusional ated lens testing than on other less natural clinical
vergence eye position in many cases of strabismus. tests, such as afterimages (Ais). The principie is that
It s not unusual to find an intermittent exotrope the more natural the testing environment, the more
who shows NRC and excellent stereopsis when likely it is that ARC will be found. Conversely, the
fusing and ARC when strabismic. As the deviation more unnatural the environment, the more likely t
becomes manifest, angle A ncreases simulta- s that NRC will be found.
neously with angle H. Therefore, the subjective Flom and Kerr,80 espousing the motor theory,
angle stays the same (zero) during the motor move- rejected the concept of depth of ARC. They con-
ment. Far from being a rigid, hard-wired adapta- tended that disagreement among various tests can
tion, ARC s found to vary considerably with be attributed to measurement error, unsteady fixa-
changes in vergence eye position. tion, or changes n the relative position of the eyes
These two theories of ARC etiology lead to dif- from one test to another. In their study, they
ferent ideas about its remediation. The adaptation employed several different tests, including (1) the
theory suggests that early ntervention is critical. Maddox rod cover test, (2) the major ambiyoscope,
NRC must be relearned by realigning the eyes by (3) the Hallden test using red-green filters and an
early surgical and optical means or by stimulating Al to measure H, A, and S, and (4) the Hering-
bifoveal localizaron using visin training tech- Bielschowsky Al test. These testing methods, how-
niques, often applied in an ambiyoscope. The ever, were unnatural in many respects. The
motor theory, however, suggests that it is necessary Bagolini striated lens test (a relatively natural test)
to train realignment of the eyes using fusional ver- was not ncluded in their study. In contrast,
gence, thus stimulating covariation. If the eyes can Bagolini and Tittarelli 81 found HARC n 83% of
be straightened by fusional vergence, then covaria- their strabismic patients using the striated lenses
tion will change the correspondence from anoma- but in only 13% using the ambiyoscope. von
lous to normal; NRC will persist as long as the eyes Noorden2 reported similar results, concluding that
remain straight. This approach s easier to apply to ARC has a depth characteristic.
exotropes than to esotropes, because patients can We believe it is prudent to perform several
be fairly easily trained in fusional convergence. tests for ARC as part of a strabismus examination.
Many investigators and clinicians tend to adv- If the clinical findings support a depth effect,
cate either one etiology or the other. We believe then this nformation should be used n deter-
there is reasonable and substantial evidence to mining the diagnosis and prognosis. Prognosis
support each theory. It may well be that there are for elimination of ARC and ultmate cure of stra-
176 Chapter 5
bismus s generally more favorable for those Dissociated Red Lens Test
patients who demnstrate an ARC response on The dissociated red lens test was recommended
only one test rather than on all tests. Further by Flom84 for assessing Correspondence as part of
research, however, s needed to resolve the ssue the minimal strabismus examination for primary
of depth of ARC. eye care practitioners. This test determines the
subjective angle (S) for distant viewing and s
Prevalence ofAnomalous compared to the objective angle (H), which is
Retinal Correspondence measured by cover test at the same distance and
Statistics on the prevalence of ARC vary, often due under similar lighting conditions. A red filter and
to the unanswered questions about which type of a 10A base-down lose prism are held before the
ARC was being considered, what testing was done, dominant eye in a normally illuminated room.
and who did the testing. In a study of 295 strabis- The fixation target s a bright "muscle" light (e.g.,
mics, ARC was reported n 45% of the cases; of the penlight). Most strabismic patients, even with
esotropes, 53% were found to have ARC, as com- considerable suppression, will then perceive ver-
pared with only 16% of the exotropes. 82 These tically displaced diplopic images of the light, red
results were based solely on major amblyoscope on top and white on the bottom. The horizontal
findings. Possibly, the rates would have been lower angle 5 s measured using sufficient horizontal
if more unnatural tests, such as Ais, had been used prism placed before the nondominant eye until
and higher with use of more natural tests. Similarly, the two images appear to the patient as vertical ly
Hugonnier et al.83 reported that in 98 cases of stra- aligned. The method of limits (bracketing) should
bismus, the Bagolini striated lens test revealed 84 always be used to increase measurement accu-
cases of ARC, the Synoptophore yielded 64 cases, racy. In the presence of strabismus, f angle S s
and use of Ais identified only 35 cases. In general, found to be zero or cise to zero, HARC s indi-
ARC s more prevalent n nfantile than n late- cated. If angle S is significantly different from
onset strabismus, n the presence of constant zero but is less than angie H, UN HARC s sug-
angles versus intermittent and small angles versus gested. If, however, angles Hand Sare essentially
large, and n esotropa versus exotropia. ARC due the same (within the limits of measurement error),
to vertical deviations s possible but, in our clinical then NRC is present.
experience, rare.
Afterimages
Testing The Hering-Bielschowsky test s the most fre-
Correspondence can be assessed indirectly by quently used Al method of ARC testing and directly
comparing the measured angles H and S. The measures angle A, the angle of anomaly. An ordi-
angle of anomaly (A) s simply calcuiated by sub- nary electronic flash attachment to a camera can
tracting the subjective angle (5) from the objec- be modified to serve as an Al generator (Figure 5-
tive angle (/-/). It s often convenient clinically to 40a). The face of the flash is masked with
use the altrnate cover test results at farpoint for opaque tape to produce a long narrow slit. A small
angle H and the dissociated red lens test results at piece of tape also s placed across the middle of
farpoint for angle S. The angle of anomaly, A, can the slit to serve as a fixation target. The unit is held
also be measured directly without reliance on at a distance of approximately 40 cm (16 in.) from
calculation from H and S. Entoptic phenomena, the patient when the flash s triggered. A 100-watt
such as the Haidinger brush and Maxwell's spot, lightbulb can aiso be modified if a sustained stimu-
may be used, but instruments for these tests are lus s desired (Figure 5-40b). The patient should fix-
not commonly found n a primary care practice. ate the masked lightbulb for 30 seconds to
The most frequently used direct measure of A s produce a vivid, sustained Al for each eye. The
done with Ais. Next in frequency s visuoscopy, procedure s as follows:
performed with the patient under biocular view-
ing conditions (discussed later in the section 1. The nondominant eye is occluded while
Bifoveal Test of Cppers). Most other clinical tests the patient fixates a central mask on a
for ARC determine A indirectly by calculating the horizontal line strobe flasher or a masked
difference between H and S. lightbulb. The exact center should be
Chapter 5 177
Portionof
a. Flash Etemem
Unmaskedby
Tape
Central Rxation
Ma* (Masked
svithTape)
QnSwtteh
b.
opaque to produce a small gap n the Al tive Al as the room illumination s increased.
for purposes of identifying the position of
the fovea.
2. After the horizontal Al s applied, occlusion
s switched to the dominant eye, and an Al
s applied n the same manner to the non-
dominant eye, except that now t s ori-
ented vert cal y.
3. The eye s uncovered and the patient is
instructed to fixate with the dominant eye a
small, discrete target on a blank (e.g., gray)
wall so that the gap n the horizontal Al s
centered on the target. A recommended
testing distance is 1 m to faciltate measure-
ment of angle A.
4. Alternately lowering and raising the room
illumination (approximately every 3 sec-
onds) helps the patient to perceive and sus-
tain both the horizontal and vertical
afterimages.
5. The negative Al s more reliable in routine
testing than s the positive Al. The negative
Al is seen n a lighted room, whereas the
positive Al is seen in a darkened room. The
patient is asked to pay attention to the nega
6. The patient s asked to describe the
location of the vertical Al n relation
to the gap n the horizontal Al. If the
vertical Al s per-ceived as crossing
the horizontal Al any place other than
at the exact center of the target, the
examiner measures the per-ceived
displacement with a centimeter
ruler and converts the measurement
to prism diopters.
AFTER-IMAGE
SEEN BY O.D.
AFTER-IMAGE SEEN BY
O.S.
PATIENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
FIGURE 5-41 Hering-Bieischowsky
afterimage test in case of esotropa
with normal retinal correspondence.
(f = fovea; O.D. = oculus dexter; O.S.
= oculus sinister.)
AFTER-IMAGE
SEEN BY O.S.
MEASURED A
PATIENTS
PERCEPTION
(CYCLOPEAN
Lf PROJECTION)
AFTER-IMAGE,
SEEN BY O.D.
the left, as point a has the directional valu of zero, and e at different locations on the nasal retina).
and the fovea projects as a temporal retinal point. Therefore, unless they are n the dentical location,
The Hering-Bieischowsky Al test s not valid a noncross will be perceived.
unless the effect of a coexisting EF is taken into In an evaluation of correspondence when EF is
account. Figure 5-43 Ilstrales this point by add- present, the first step is to measure E using a grad-
ing to the case presented in the previous examples uated reticule in an ophthalmoscope. Angle A
the condition of nasal EF of the right eye. A perfect may then be determined by measuring the separa-
cross s perceived if the angle of EF (E)and A are tion between the vertical Al and the center of the
the same in direction and magnitude. Points a and gap of the horizontal Al and adding to this the
e are n the same location on the retina. In such a magnitude of E. Assume, for example, an E of 5A
case, the patient has point e stimulated with the is found (Figure 5-44). If the patient looks at the
vertical Al during monocular fixation with the right Ais at 1 m, each centimeter of displacement rep-
eye. Because this s the same point on the retina resents 1A. The patient then reports seeing the ver-
that corresponds to the fovea of the left eye, the tical Al off to the left by 10 A. This is the measured
patient will project the vertical Al in the same A but not the trueA. The magnitude of E(5An this
direction as the gap in the horizontal line. This is example) must be added to this measured A to
an exceptional case and not the rule: f and A us- arrive at the true angle of anomaly. It is easily
ally are not of the same magnitude, althbugh they seen that the angle between the fovea and point a
most often are in the same direction (e.g., points a is equal to 15A (not the 10A as measured).
Chapter 5 179
AFTER-IMAGE
SEEN BY O.S.
AFTER-IMAGE
SEEN 8Y O.D.
I1 POINT "a"
AND
POINT "8"
FIGURE 5-43Example of esotropa
with anomalous retinal correspon- PATIENTS PERCEPTION
dence and eccentric fixation. In this (CYCLOPEAN PROJECTION)
particular case, the angle of eccen-
tric fixation is the same as the angle
ofanomaly. (f = fovea; O.D. = ocultis
dexter; O.S. = oculus sinister.)
AFTER-IMAGE
SEEN BY O.S.
AFTER-IMAGE
SEEN BY O.D.
POINT e
FIGURE 5-44Esotropa with harmo-
nious anomalous retinal correspon-
dence and nasal eccentric fixation, n ;V ^--ANGLE E
which the angle of eccentric fixation . ^MEASURED
ANGLE A
and the angle of anomaly are
unequal. Angles A and E must be
summed to determine the true angle PATIENTS PERCEPTION
MEASUREDA (CYCLOPEAN PROJECTION)
of anomaly. (f = fovea; O.D. = oculus
dexter; O.S. = oculus sinister.)
It s not always necessary to use an Al for each Conveniently, A and E measurements can be
eye as n the Hering-Bielschowsky test. The Brock- combined into one procedure by using a Haid -
Givner Al transfer test is another means of measur- inger brush (HB) and an Al (Figure 5-45). The sepa-
ng A. For this test, only one Al is applied to the ration between the Al and HB represents A. In this
fovea of the dominant eye, which then is occluded. example, there s no EF. If there were EF, the HB
The projection of the Al s transferred intracortically would be displaced from the fixated black dot, the
to point a of the strabismic eye. Assume, for exam- magnitude representing that of E. In summary, E is
ple, that a strabismic left eye s occluded and the measured by the displacement between the dot
dominant right eye s stimulated with the vertical Al. and the HB, whereas A s measured by the distance
The occluder is switched to the right eye, and the between the Al and the HB.
left eye fixates a black spot on a gray wall at 1 m.
The displacement of the fixated spot from the Al Bifoveal Test ofCppers
represents the angular magnitude of A. It s only Most tests for ARC have one or more shortcom i hgs,
when there is no EF (E = 0) that the displacement the most common being the contamination of EF.
between the fixated spot and the perceived Al repre- The bifoveal test of Cppers can elimnate this pos-
sents true A. Angle E must be added to the measured sibly invalidating factor. It s particularly useful in
A to calclate true A. Thus, true A = measured A + assessing correspondence n cases of strabismic
the magnitude of EF (At - Am + E). amblyopia. Testing is done by performing visuos -
180 Chapter 5
blackdo
t and
HB
Opaque
Occluder
f flashing
light
MITT
copy under binocular seeing conditions for the unless suppression is very deep and extensive. If
measurement of the angle of anomaly (A). This so, a red filter can be used to produce a red light
should not be confused with the procedure for stimulus to the left eye. This almost always breaks
measurement of the angle of EF (f) under monocu- through any existing suppression.
lar seeing conditions. The examiner's next step is to project the star
The bifoveal procedure is illustrated in Figure directly onto the fovea and to ask the patient to
5-46. Suppose the patient has an esotropa of the report the direction in which the targets are seen. If
right eye. An angled mirror (or a large base-out there is NRC, the patient should report that the
prism of approximately 40A) is placed before the penlight and the star are superimposed (see Fig-
patient's dominant left eye to fixate a penlight off ure 5-46b), because both foveas correspond to
to the side from a distance of 2-3 m (see Figure one another. If, however, the foveas do not corre-
5-46a). This s necessary so the patient can main- spond (ARC), as in Figure 5-46c, the patient will
tain seeing under binocular conditions without report that the star and penlight appear separated
one eye being occluded by the examiner's head in space, even though both foveas are being stimu-
during visuoscopy. The next step is for the exam- lated. In this case, the examiner should move the
iner to look into the patient's right (amblyopic) eye star nasalward to find point a so that the penlight
and observe the image of the star that is projected and the star are superimposed (see Figure 5-46d).
on the patient's retina. If mydriatics are not used This is necessary because point a corresponds to
for pupil dilation, a darkened room is recom- the fovea of the left eye. The distance from point a
mended. At the same time, the patient is asked to to the center of the fovea (f) represents the magni-
look into the instrument for the star on the grid of tude of A. This distance can be measured by using
the ophthalmoscope (visuoscope). The patient projected concentric circles of a reticule. If a direct
should be aware of both the penlight and the star, ophthalmoscope without a reticule is used, retina!
Chapter 5 181
a. b.
DOCTOR SUSPENDS
VISION IN O.S.
C.
d.
STAR SEEN BV DOCTOR
PROJECTED ONTO
PATIENTS FUNDUS
STAR QRATICULE
IN VISUSCOPE
STAR GRATICULE
IN VISUSCOPE
DOCTOR SUSPENDS
VISION IN O.S.
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 patient with anoma-
lous retinal correspondence to achieve superimposition of the penlight and the star. (O.D. = oculus dexter; O.S. = oculus sin ister.)
landmarks, such as the optic disk (or optic disc), (23A) and the outer margin 18.25 degrees (33 A)
can be observed to estmate the magnitude of A. from the center of the fovea (Figure 5-47).
Knowing that the center of the disk s normally The bifoveal visuoscope test, therefore, takes
15.5 degreesfrom the center of the fovea helps n much of the guesswork out of measuring A as
estimating the distance from the star to the fovea. compared with other, more subjective methods of
Likewise, if the width of the disk s 5.5 degrees, the testing. In addition to this advantage, the pres-
first margin of the disk would be 12.75 degrees ence of EF does not need to be taken into account
182 Chapter 5
K.) The examiner should sight from behind the account when determming the presence of ARC.
tube to ensure the greatest accuracy. 3. The Allowance of 1-2A error may be necessary for small
method of limits (bracketing technique) is angles, and up to 5A should be allowed for large
used to determine the symmetric position of angles of strabismus n comparing /-/and S.
the corneal reflections. Then the magni-tude Another quick check for ARC on the Synopto-
of the objective angle (H) s read directly phore is the unilateral douse target test. This s
from the prism diopter scale of the done after angle S has been measured and the tar-
nondominant eye. gets appear to be superimposed. The examiner
simply shuts off (douses) the illumination to the tar-
The procedure for finding the horizontal subjec- get of the dominant eye and watches for move-
tive angle (S) with the Synoptophore s as follows: ment of the nondominant eye. If the nondominant
1. After the instrument has been adjusted prop- eye makes a horizontal movement to fixate the
erly for the patient, the examiner should center of the target, ARC is presumed to be
insert.two first-degree targets, one before present, and there is a difference between angles S
each of the patient's eyes, of sufficient size and H. This test, n effect, is a unilateral cover test.
to avoid or minimize suppression (e.g., the The size of the movement represents the magni-
fish and tank targets). Because this is a bin tude of angle A.
ocular test, neither eye is occluded. For example, suppose a patient has a 15A right
2. The patient s nstructed to maintain fixa- esotropa (angle H; i.e., 15A base-out by altrnate
tion constantly on the center of the domi- exclusin as measured on the Synoptophore). The
nant eye's target (e.g., fish), which is set to fish and the tank, however, appear to be superim-
the zero position on the scale. posed at 9A base-out (angle S), which represents a
3. The patient (or the examiner, if necessary) significant difference from the measured objective
adjusts the position of the nondominant eye's angle. ARC is, therefore, suspected. On the douse
tube (e.g., with the tank) until the two targets target test, when the left eye s doused, the exam-
appear superimposed (.e., the fish inside the iner observes an outward movement of the right
tank). If suppression occurs, the illumination eye of approximately 6A to pick up fixation on the
can be ncreased for the suppressing eye or target. This is a positive douse target test, confirm-
dimmed for the dominant eye. ing the presence of ARC. (As discussed previously,
4. The magnitude of the angle S is read directly however, any EF must be taken into account.)
from the scale, and the measurement is
Bagolini Striated Lenses
taken several times, approaching angle 5
from both sides (bracketing technique) to The Bagolini striated lens test is a quick, simple, and
increase accuracy. informative clinical test for ARC n strabismic
patients. Striations n Bagolini lenses are so fine that
Determining the subjective angle sometimes is the patient is unaware of them, therefore making the
difficult, due either to deep suppression or to hor- test a fairly natural one for the subjective angle (5).
ror fusionis. Vertical dissociation can sometimes The striations cause a streak of light to be visible
overeme these obstacles, allowing the measure- when the fixation target s a bright spot of light, simi-
ment of angle S. Using the vertical adjustment, the lar to the effect of a Maddox rod (Figure 5-48). Vari-
Synoptophore target to the nondominant eye s ous perceptions during this test are illustrated n
eevated 10A or more above the other target. The Figure 5-49. Bagolini lenses do not disrupt binocular-
nondominant eye's target is then moved horizontal ity or significantly reduce visual acuity or contrast
ly until the one appears exactly above the other. sensitivity.85 A patient bifoveally fixating a penlight
This valu represents the subjective angle. Another will see the penlight at the intersection of the streaks,
procedure that is effective is using a large first- as in Figure 5-49c. If the patient has a manifest stra-
degree target before the nondominant eye while bismic deviation whereby bifoveal fixation s not tak-
the patient s fixating a small target with the other ing place, diplopic images of the light occur, unless
eye (e.g., the Xand the sentry box) (see Figure 5-6). suppression s too intense and extensive. Often, how-
After angles H and S are measured on the Synop- ever, only a portion of one line will be missing, as in
tophore, t is a simple matter to calclate angle A (A Figures 5-49d and 5-49e. An esotropic patient is nor-
= H-S). Measurement accuracy must be taken into mally expected to have homonymous diplopia and
184 Chapter 5
this procedure. This test should be done quickly to split evenly down the middle suggests UNHARC.
avoid possible contamination of prism adaptation. Although color fusin testing s not completely
The great majority of strabismic patients with reliable, it does seem to have some diagnostic and
ARC show HARC on the Bagolini test. HARC s an prognostic valu. For example, a patient who
ideal antidiplopic adaptation for a strabismic indi- shows a Swann split-field effect without contours
vidual n natural seeing conditions at school, work, in the visual field has a poorer prognosis for suc-
or play; some peripheral binocularity, with its cessful treatment of ARC than does a patient
many benefits, often s preserved. The Bagolini test reporting color fusin over the entire field.
is relatively natural; clinicians find the highest
prevalence of ARC using this test as compared with
other, less natural clin cal methods.
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chaptere / Diagnosis and Prognosis
useful n evaluating functional success. Manley3 efficient and effective functional visin training
indicated that a stereothreshold of 67 seconds of are (e.g., frequent change of doctors, poor patient con-
(for contoured tests) s the differentiating valu trol, group therapy). A higher rate of success was
between monofixation pattern and bifoveal fusin reported by Etting,6 who surveyed a random sam-
and, for example, that on the Stereo Fly tests "central pling of 42 cases reported by an optometrist n a
fusin (bifixation) must be present for cirels 7 to 9 prvate practice. There were 20 exotropes, 6 of
to be answered correctly." This compares closely whom had constant strabismus, and 22 esotropes,
with the findings on the Pola-Mirror test, n which 18 of whom had constant strabismus. Using Flom's
central suppression was found n al I patients whose criteria, the overall functional cure rate was 64%:
stereoacuity on contoured tests was worse than 60 85% for exotropia and 45.4% for esotropa. Seven
seconds of are, whereas al I those whose stereoacu- patients were known to have undergone surgery
ity was better than 60 seconds passed the Pola- prior to training, but there was no subsequent sur-
Mirror test.4 Therefore, we believe the cutoff valu gery for any of the patients n this study.
of 67 seconds or are s reasonable and should be A well-documented strabismus report in which
included n the criteria. This stereoacuity criterion surgery was the dominant method of therapy is the
can be one of the means of determining whether study by Taylor,7 who found that in cases of con-
strabismus is completely eliminated (.e., when genital esotropa, there was not one nstance of
there s bifoveal fixation without suppression). A functional improvement when surgery was accom-
realistic cutoff for noncontoured stereoacuity tests plshed after the second birthday. However, he did
would be 100 seconds of are. Although there are believe it possible to achieve functonal cure in
exceptions, the general rule is that stereoacuity is such cases f surgery was performed early (.e.,
the "barometer" of binocular status. before 2 years of age), and partcularly if dligent
It should be pointed out that a patient who has (mnimum of 5 years) follow-up care were given.
made either modrate improvement or slight There s no hope for functional results unless sur-
improvement may not be much better off from a gery results n a deviation that s 10A or less hori-
practical standpoint. These labels are sometimes zontally and 5A or less vertically. In a selected
nothing more than academic, as they are useful sample of 50 such patents undergoing early sur-
only n statistical analyses of reported studies. For gery, 30 were later found to have stereopsis rang-
example, suppose ARC is temporarily eliminated ing from 40 to 400 seconds. Of these 30 patients, 4
but the patient still has esotropa, suppresson, and had stereoacuity of 40 seconds of are on the Stereo
the like. The important queston that should be Fly test. Taylor, therefore, advocated early surgery
answered by the doctor is whether the patient s in cases of congenital esotropa, believing that late
actually any better off as a result of having had an surgery is hopeless wth respect to achevng a
improvement. There are, however, possible psy- functonal cure. Early surgery is currently consd-
chological benefits for these patents when they ered to be the most efficacious means of treatment
feel they have been helped. These results should in cases of infantile esotropa, partcularly f the
be evaluated and put in their proper perspective. condition is congental. This applies also to infan-
However, most reported studies giving rates of tle constant exotropia, although this condition is
cure have not incorporated such complete and less prevalent than infantile constant esotropa.
defintive criteria as those of Flom.1'2 Consequently, Cases of acquired strabsmus usually are helped
it is difficult to evalate their significance. One of by some or al I of the other methods of therapy. The
the exceptions, however, s the survey by Ludlam.5 use of surgery for achievng functional cure in
In this study of 149 strabismic patients, the previous cases of acqured strabismus should be considered
criteria of Flom were followed strictly. Treatment did in patients who fail to respond to nonsurgical
not nclude surgery or drugs, whch kept the study means of therapy. Table 6-2 classfes these types of
"clean" as compared to most others, n which the strabismus according to time ofonset An expected
effects of surgery cannot be delineated from nonsur- prognosis s Usted for each category, but t is in no
gcal methods. According to Ludlam,5 the reported way meant to apply to all cases wthin each cate-
functonal cure rate was 33%, and the almost-cured gory. (Further classificaton of types of strabsmus is
rate was 40%, with the remaining percentage being dscussed n Chapter 7.)
dstributed among the other categories. Most cases of comtant, nonaccommodative,
Ludlam's study took place at a large teachng acquired strabsmus are diopathic (i.e., unknown
clnic setting with many nherent disadvantages for cause). Although there are genetic trends in
192 Chapter 6
TABLE 6-4. Model for Estimating the Probability of Functional Correction of Different Types of Squint and
Associated Factors
Esotropa Exotropia
Occasional Occasional Constant Constant Eght Basic Constant Constant Occasional Occasional
NRC ARC NRC ARC Squint Types ARC NRC ARC NRC
0.60 0.50 0.30 0.10 Basic probabili- 0.40 0.50 0.70 0.80
,ties
+ Factors (add
0.1)
0 0 O O Good second- {) ( ) (_) {_)
degree fusin
O O O () Family historyof (_) (_) (_) (_)
squint
0 0 {) 0 No amblyopia O O O O
O 0 Deviation <!&* (-) (-) (_) (_)
(-) (-) - Factors (sub-
tractO.1)
O 0 O (-) Marked suppres- (-) (-) <-) (-)
sion
o o O (-) Marked incomt- O U O O
tancy
Deep amblyopia O O O 0
o
O
o0 0
o o
O Estimated prob- 0 O
ability
o o
ARC = anomalous retinal correspondence; NRC = normal retinal correspondence.
Source: From Flom MC. Issues n the Clnica! Management of Binocular Anomalies. In: Principies andPractice ofPediatrc Optometry.
Rosenbloom AA, Morgan MW, eds. Philadelphia: Lippincott, 1990, with permission.
list, including general rules, is provided nTable 6-3. cure by any and all means of visin therapy,
Flom developed a quantitative scheme for deter- which may include surgery. If, n the given case,
mining the prognosis for a given case (Table 6-4). there is deep suppression, the prognosis would be
(Note that his term for strabismus is squint and for lowered to 80%. If there are also marked noncom-
ntermittent it s occasional.) In Flom's scheme, the tancy and deep amblyopia, the prognosis would
three most mportant prognostic factors are (1) direc- be 60%. The second significant factor is fre-
tion of the deviation (eso or exo), (2) constancy of quency. For example, ntermittent esotropa with
the deviation (ntermittent or constant), and (3) cor- NRC would have a 60% chance for functional
respondence (ARC or normal retinal correspon- cure, as compared with 30% for constant esotro-
dence [NRC]). We explain Table 6-4 using the. pa with NRC.
following example: In a case of intermittent Although this scheme has nstructional valu
esotropa with NRC, the basic probability for func- for students and can serve as a hypothetical
tional cure s 60%. If there s good second-degree guideline for practitioners, we believe t s
sensory fusin, a family history of strabismus, and unwse to depend entirely on statistical models to
no amblyopia, the prognosis would be improved make a prognosis for a particular patient wth
by 10 + 10 + 10 (total of 30%), yielding a progno- strabismus. Instead, the doctor must take into
sis of a 90% chance for achieving a functional account all the variables, assocated conditons,
Chapter 6
The presence of ambiyopia is a stumbling block that the prognosis may be somewhat better if indi-
to the successful treatment of strabismus. Fortu- rect occiusion is tried initially.
nately, ambiyopia can be detected and treated at Chavasse14dscussed the concepts of ambiyopia of
an early age. Once ambiyopia s eliminated, stra- arrest and ambiyopia of extinction. Ambiyopia of
bismus therapy is facilitated. arrest s a failure n the development of visual acuity
We agree with Winter,10 who suggested that due to strabismus, anisometropia, or other conditions
practically all cases of strabismic ambiyopia or (e.g., cataract). In any event, the development of
anisometropic ambiyopia can be cured by direct visual acuity s arrested at the time of onset of the
occiusion alone, provided that the child s younger causative condition. The prognosis for improving
than 4 years, and that from ages 4 to 6 years the visual acuity in a documented case of ambiyopia of
prognosis s often good. However, extensive treat- arrest is considered to be very poor. This s probably
ment may be required. Aust11 similarly stated that true if the patient is beyond the developmental age
occiusion therapy can lead to a cure of ambiyopia (probably 6 years or older). However, f the same
in more than 90% of cases up to the fifth year of type of case is treated at a much earlier age, the prog-
life, whether or not fixation s central. Goodier12 nosis may be better. Ambiyopia of arrest, therefore, is
used direct occiusion for 46 ambiyopic patients up not always a deterrent to treatment if the patient is
to the age of 9. An mprovement in fixation and very young; but if treatment is delayed until the child
visual acuity was reportad n 44 cases. It was con- is older, the prognosis becomes worse.
cluded that the use of inverse occiusion did not The prognosis for a case of ambiyopia of extinc-
appear to be as efficacious as direct occiusion. tion s thought to be good regardless of the age at
Many disagree with the contention that direct which treatment is begun. However, an older
occiusion s always the best method of occiusion patient may require a rnore lengthy therapeutic
therapy. If a patient older than 5 years has eccentric program than a younger patient. Ambiyopia of
fixation, direct occiusion s thought to cause the extinction s a condition in which visin has dete-
abnormal fixation to become even more deeply riorated because of suppression resulting from
embedded. If this happens, very specialized pleop- either strabismus or anisometropia. The visin that
tic therapy using afterimages and entopic foveal was once lost can usually be recovered through
"tags" may be necessary to treat the abnormal fixa- the re-education process of visin therapy.
tion. The contention is that inverse occiusion would Chavasse's concepts14 are not undisputed. Many
have prevented the degree of embeddedness that authorities have refuted them on the basis of find-
resulted from direct occiusion. Kavner and Suchoff13 ings that ambiyopic therapy results do not always
reported that prognosis is poorer when there s a sta- correspond to the level of visual acuity that s tradi-
ble eccentric fixation as opposed to one that is tionally expected. Often in cases of relatively
unstable. They recommended inverse occiusion and early-onset ambiyopia, better acuity s achieved
specialized pleoptic training when dealing with this than was believed possible, which would appear
type of condition. to contradict the concept of ambiyopia of arrest.
We believe that direct occiusion s the proce- However, f modern normative visual acuity levis
dure of choice in ambiyopic patients up to 6 years expected for certain ages are properly matched
of age. In patients older than 6, direct occiusion with the time of onset, the concept of ambiyopia of
should be tried f fixation s central or if unstable arrest is on solid ground. The apparent mismatch
eccentric fixation is present. The prognosis may be arse because of the od assumption that an infant's
fair or good depending on the circumstances. visin is poorer than it actually is. Chavasse 14
However, n patients older than 5 years who have believed that the acuity level of a 4-month-old
steady eccentric fixation, the prognosis for elimi- child s normally approximately 20/2500, but
nating the eccentric fixation and ambiyopia by research has shown this to be untrue: Infants'
means of direct occiusion alone may be poor. Very visual acuity is much better than was expected in
often when direct occiusion is used in this type of the past. This may explain why treatment n cases
condition, there is an immediate small mprove- of early onset s often successful; perhaps the con-
ment in visual acuity but no further gain afterward. dition being treated s not ambiyopia of arrest but
This may be so because the eccentric fixation rather ambiyopia of extinction.
becomes very entrenched, making it difficult to The presence of ARC is a very unfavorable factor
reduce it any further. Therefore, the contention s in the prognosis of esotropa. Flom1 reported that
196 Chapter 6
whereas ARC is highly unfavorable in cases of con- mental history that is normal can be considered
stant esotropa, it is of less significance in cases of favorable in many cases.
constant exotropia. The cure rates of Ludlam3 were Testing for sensory fusin at the centration point
reported to be 23% for esotropes with ARC and is another important supplemental prognostic pro-
86% for esotropes with NRC. Exotropes with ARC cedure. Plus-power lenses may be efficacious for
had a cure rate of 62%, as opposed to 89% for bringing the eyes to the ortho posture. The appro-
those with NRC. Etting 6 reported a cure rate of priate amount of plus-lens power and the centra-
10% for esotropes with ARC, as opposed to 75% tion point distance (the point at which the visual
for esotropes with NRC. The cure rate for exotropes axes cross) must be determined. For example,
with ARC was 50%. It appears that ARC is a seri- assume a 15A esotropa and an interpupillary dis-
ous factor in cases of esotropa but is less influen- tance (IPD) of 60 mm. The centration point would
tial in exotropia. be 40 cm from the patient, which is determined by
Lack of correspondence is considered to be calculating the lens power that will place the eyes
extremely unfavorable. Current therapies offer no in the ortho posture, using the following formula:
hope for a functional cure in the older child or
adult who has a complete lack of correspondence.
Lens power (in diopters) = H/IPD
The best recommendation in such cases is either where H is the horizontal objective angle of devia-
no treatment or an attempt at cosmetic cure. tion expressed in prism diopters and the IPD is
In cases of horror fusionis, the usual recommen- expressed in centimeters. From this example, if 15 is
dation is no treatment because the prognosis is divided by 6, the quotient is 2.50 diopters (D). The
poor. If the ARC can be broken, however, horror distance at the centration point is the focal distance
fusionis may not be a significantly adverse factor of the lenses (100/2.50 = 40 cm). If 2.50-D lenses are
for functional cure, assuming that the horror fusio- worn, the patient is seeing at 40 cm as though at opti-
nis was produced by the ARC. (See Chapter 5.) cal infinity. The horizontal deviation should, there-
Accommodative infacility is not an unfavorable fore, become ortho at the 40-cm test distance with
factor in strabismus; however, itfrequently accom- the patient wearing the +2.50-D lenses (Figure 6-1).
panies amblyopia with eccentric fixation. Accom- That being so, various sensory fusin tests can be
modative flexibility training (so-called rock) often conducted (e.g., Worth four-dot and stereopsis tests).
is used as part of amblyopia therapy, and consider- The centration point calculation is theoretical, in
able time may be required before both the fixation the sense that the visual system does not always work
and accommodation improve. in a predictable mechanical manner. For example, in
There are poor fusiona! vergences in strabismus. some cases of esotropa, plus-power lenses seem to
Sensory fusin must be attained so that disparity have little or no immediate effect, and only on pro-
vergence can be established. When this is accom- longed wearing (e.g., 1 hour) may there be reduction
plished, fusional vergence ranges can often be of the deviation toward the centration point. Further-
increased by means of visin training. The progno- more, many esotropic patients (particularly those
sis for functional cure of strabismus, therefore, is with ARC) revert to their original angle and over-con-
not necessarily poor because of poor fusional ver- verge for the concentration point.
gences prior to visin therapy. Cooperation is a vital factor in treatment when
visin training techniques are used. A patient must
Other Factors be perceptive and of reasonably good intellect to
The time of onset, mode of onset, and duration of go through this form of therapy. In addition, genu-
strabismus, previous treatment, developmental ine interest of the patient and, in the case of a child
history, and additional evaluative procedures all patient, of the parents is extremely helpful. In fact,
play important roles in determining the prognosis cooperation and interest may explain the irony of
in any case of strabismus. The prognosis is better the favorability of a family history of strabismus:
when the onset of amblyopia or strabismus is later Parents may be motivated to do something about
rather than earlier. A short duration is better than their child's condition because of their familiarity
a long one, as immediate therapy increases the with binocular anomalies.
chance for cure. Existing anomalies that were The age of the patient is an important factor,
once successfully treated often are easily elimi- often dictating what form of therapy the patient
riated by re-education. Furthermore, develop- will receive. Vision training can best be done when
Chapter 6 197
VISION THERAPY
Pharmaceutical
Treatment
Pleoptics
(Specialized Therapy
for
sensory-motor
amblyopia
with eccerrtric
fixation)
Cure of Deficient
Binocular Visual Skills
Enhancement of
Binocular Visual Skills
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 ver- b.
gence ranges, and improving the reflex aspects of
ocular motility. For this reason, orthoptics has the
FIGURE 6-4
greatest utility in cases of intermittent strabismus, Extraocular muscle
heterophoria, and deficient oculomotor skills. surgery nvolving a rectus muscle. a. Recession as a weakening
Many orthoptic techniques (ncluding monocu- procedure. The insertion of the tendn is removed and reattached
posteriorly n the globe. b. Resection as a strengthening procedure.
lar regimens) are used in the treatment of amblyo- The tendn or muscle s cut and a portion is removed; then t is
pia, but pleoptics (literally "full sight") is a specific rejoined.
type of training designed exclusively for amblyopia
with eccentric fixation. These techniques involve
light stimulation techniques to diminish the nflu- briefly as one of several alternatives for treating bin-
ence of the eccentric fixation point n the ambly- ocular anomalies. Many fine books covering the
opic eye and enhance foveal fixation. In some details of surgical procedures for extraocular mus-
cases of severe amblyopia of long duration, both cles and other anomalies affecting ocular motility
pleoptic and orthoptic techniques, as well as an are available for reference purposes. Particularly
aggressive patching (occlusion) program, are good among these are publications by Hugonnier et
required to achieve a successful outcome. al.,20 Hurtt et al.,21 Mein and Trimble,22 von
Visual perception training techniques to improve Noorden,23 and Dale.24 In addition, several case
information processing, for certain types of learning reports are ncluded n the treatment chapters of this
disabilities, are not discussed n this text. However, book that describe various surgical approaches.
many perceptual training techniques (e.g., figure-
ground, visual discrimination, and closure) are used General Approach
to treat amblyopia.
The general approach to extraocular muscle sur-
gery is that the action of a particular muscle should
Extraocular Muscle Surgery be made either weaker or stronger. Examples of
The surgical form of binocular therapy may be nec- weakening procedures include recession, tenot-
essary n certain cases when the angle of deviation omy, tenectomy, myotomy, and myectomy. When
is too large to be consistently and easily overeme the muscle is recessed, the nsertion is moved from
by fusional effort or when a significant noncomitant the original site and transplanted to another loca-
deviation s present. Many different procedures are tion to produce less mechanical advantage (Figure
used by ophthalmologists in extraocular muscle sur- 6-4a). Another weakening procedure is tenotomy,
gery. Some basic principies, however, are accepted either marginal or free (i.e., disinsertion at the
by most ophthalmic surgeons. Only those general scleral attachment). In many varieties of controlled
approaches to correction of deviations of the visual tenectomies, the tendn s appropriately cut for
axes are discussed n this book; we do not intend to weakening the action of an overacting muscle.
cover this subject in depth but merely introduce it
202 Chapter 6
Either myotomy or myectomy is the term used ation can probably be expected. In a study of 88
when the muscle, rather than the tendn of the patients with esotropa, Aust and Welge-Lussen26
muscle, s altered. found that the angle of deviation increased in
Examples of strengthening procedures nclude 71.5% of the patients over a period of 5-9 days.
resection, tucking, and advancement. Resectioning ARC was thought to be more commonly associ-
of a muscle or tendn changes the angle of devia- ated with the increase than was NRC.
tion by shortening it (see Figure 6-4b). The method Alpern and Hofstetter27 reported a well-docu-
of tucking may nvolve the tendn or the muscle; it mented case of esotropa in which the angle of
also effectively serves to shorten the muscle. deviation increased by the same amount as the
Advancement of the insertion serves to strengthen power of the compensatory prisms. The 14A strabis-
the action of the muscle by giving it greater mus was constant and unilateral, and the presence
mechanical advantage. of ARC was clearly established. Base-out prisms
The prism adaptation test (PAT) was introduced having a total power of 18A were worn for 5 days.
by Woodward and reported by Jampolsky.25 Sur- The rate of increase of the angle of deviation was
geons use this test procedure to estmate the rapid within the first 3 hours, with only a slight,
amount of surgery required for alignment. PAT is gradual increase over the nextfew days until taper-
used to predict success (often when surgery is ing to the mximum of 32A (total increase of angle
anticipated) in cases of esotropa. The testing pro- H of 18A). After prisms were removed, angle H
cedure involves the applcatin of base-out prism decreased rapidly (within a few hours), but it was
for the manifest eso deviation. The patient wears approximately 1 week before the strabismus finally
prisms for some time, usually an hour, while the was reduced to its original angle of 14A.
clinician measures the angle of deviation at certain Postar28 investigated the use of the PAT for eso-
intervals, usually every 10 minutes. Jampolsky25 tropic patient-s. He concluded that changes in the
recommended overcorrecting for the patient's con- angle of deviation were related to the status of sen-
dition by using a prism power that is slightly stron- sory fusin. The overconvergence reaction to the
ger than the magnitude of the esotropa. For small base-out prisms did not tend to occur when sen-
deviations, an overcorrection of 5A is recom- sory fusin was good, but the tendency was evi-
mended, whereas for larger deviations, a 10A over- dent when sensory fusin was poor. He advocated
correction is suggested. For example, suppose a mproving stereopsis early in the therapy program
patient has esotropa of 25A. The patient is given to keep the deviation from increasing when prisms
35A base-out prisms to wear for 1 hour. Fresnel are applied. He further concluded that the 1-hour
prisms are more comfortable for the patient than testing time was too short and a longer period
are glass or plstic clip-ons. The immediate mea- should be allotted for evaluating the effects of
surement on the altrnate cover test should show a prism adaptation.
10A exo movement. In many cases, the exo will In taking a different approach to prism adaptation
decrease in a very short time and, after approxi- testing, Crter29 found that heterophoric individuis
mately 10 minutes, the patient will exhibit an eso with good binocularity and without symptoms
movement on the cover test. In some cases, the eso showed the same magnitude as the original hetero-
deviation becomes larger that the original devi- phoria before prisms were worn. Thus, a 5A esophore,
ation. Assume that after an hour the altrnate cover corrected with 5A base-out prisms, still showed 5A of
test shows a 20A eso movement of the eyes. The esophoria by cover test through the prisms that were
eso deviation is now 35A plus 20A, or a total of 55A. worn for approximately 30 minutes. In contrast,
The angle of the deviation has more than doubled individuis who had heterophoria and asthenopia
in magnitude as a result of the PAT. (possibly with fixation disparity) accepted compen-
Jampolsky25 believed that this indicated a poor satory prisms. Their symptoms were relieved, and
prognosis for cure by surgery and probably by there was no prism adaptation effect.
other means as well. If the deviation had remained From the preceding reports, we can conclude
the same or had increased only slightly, the prog- that prism compensation should be considered in
nosis would have been considered much better. As cases of heterophoria with symptoms. In contradis-
a rule, in more than half of the cases of esotropa, tinction, the magnitude of deviation in heterophoric
after a patient has worn compensating prisms for at patients without symptoms will likely increase as a
least 2 or 3 hours, an increase in the angle of devi- result of the wearing of compensatory prisms. In the
Chapter 6 203
case of esotropa, the deviation s likely to ncrease geon's knots and the muscle tendn adheres per-
when sensory fusin is poor (e.g., ARC and suppres- manently to the sclera during the healing process.
sion). If, however, sensory fusin s good, the stra- This procedure can be used with any of the rectus
bismic deviation s likely to stay the same or muscles and the superior oblique tendn. Both verti-
increase only slightly. On rare occasions, the basic cal and horizontal muscles can be put on adjustable
deviation appears to be reduced in magnitude as a sutures when strabismus s present n both direc-
result of wearing prisms. tions. Adjustable sutures are particularly appropriate
It is generally agreed that little or no ncrease when the outcome s not readily predictable (e.g.,
*or, as occasionally happens, a decrease) n the cases of previous unsuccessful surgery) or when the
angle of strabismus on the PAT is an indication of patient has fusin potential and precise alignment is
a good prognosis. However, there is incomplete critical to a successful outcome, as n cases of thy-
agreement as to the nterpretation of the results of roid ophthalmopathy. Some strabismus surgeons use
the PAT when the angle mercases significantly. adjustable sutures n nearly every case of rectus
The majority opinin holds that the prognosis s muscle surgery. Efforts have been made to extend
unfavorable n these nstances, but some authori- the time between the operation and the postsurgical
35
ties believe there may be exceptions to the rule. adjustment using medications, but there s little
Some cases result n a functional cure despite dis- change in the final outcome by delaying the adjust-
mal expectations that were derived from the PAT. ment until 24 hours as opposed to only a few hours
36
This points out the need for practitioners to be postoperatively. The reoperation rate after conven-
cautious when making a prognosis and not to rely tional surgery is estimated to be 19-35%, as com-
too much on any one test. pared with 4-10% using the adjustable suture
37
technique.
Adjustable Suture Procedure
30
Jampolsky pioneered the adjustable suture tech- Surgcal Consderations
nique for extraocular muscle surgery, which allows Most patients and parents are natural ly apprehensive
a surgeon to refine the surgical result within 24 about undergoing strabismus surgery. The doctor
hours after the operation. Many surgeons find that must give realistic information regarding the potential
this procedure improves their long-term results. At complications and what is involved in the procedure.
the very least, the adjustable suture procedure This nformation usually relieves some anxiety. The
helps to avoid large overcorrections and undercor- patient should be encouraged to ask all possible
31
rections. The severed muscle tendn s not reat- questions during the preoperative visit. For medicole-
tached tightly to the sclera at the time of the gal purposes, the surgeon should document in the
operation. After the muscle s resected or recessed patient's record the specific complications that were
by the necessary amount, long sutures in the ten- discussed. Not every potential complcatin need be
38
dn are passed through the superficial sclera and mentioned, however. According to Helveston, pre-
are secured externally with a slipknot. Under a operative informed consent requires a discussion of
local anesthetic, the final adjustment of alignment at least three possibilities: diplopia, loss of visin, and
can be made on the same day of the operation or need for reoperation.
the next day while the patient s awake. Most Depending on the age and sensory status of the
adults and many school-aged children can cooper- patient, diplopia s a common occurrence during
32
ate adequately with the procedure. Using the the nitial postoperative phase of healing. Most
cover test to check alignment, the surgeon loosens patients experience only transient diplopia that
the slipknot and repositions the muscle insertion as disappears within a week or so after the operation.
needed. The lose ends of the sutures are pulled to Older patients tend to notice diplopia more often,
advance the insertion (a strengthening procedure) as one might expect. If the diplopia s debilitating,
or are pulled n the opposing direction to achieve the patient can wear a patch or be given a Fresnel
more recession (a weakening procedure). There is prism in an attempt to achieve sensory fusin.
a linear relationship between the millimeters of Many patients will notice diplopia only if they
adjustment and the change n the strabismic devia- consciously look for t n some extreme field of
33
tion. The adjustment procedure can alter the gaze; this behavior should be discouraged. Diplo-
A 34
deviation by up to 23 . The dissolvable sutures pia that disrupts the normal course of daily activi-
then are secured in position externally with sur - ties is cause for concern.
204 Chapter 6
An extremely rare but serious complcatin of tests are completed. The anesthesiologist usually
strabismus surgery s loss of visin. This devastating meets with the patient or parents immediately
compl catin can be caused by perforation of the before the operation to check the patient and to
sclera and retina with a surgical instrument or nee- ensure that the preoperative instructions from the
dle. Loss of visin in this event occurs subsequent hospital have been followed. The strabismus oper-
to retinal detachment, vitreous hemorrhage, cata- ation itself usually takes only 1 hour, give or take
ract, glaucoma, optic nerve incisin or transection, 15 minutes. Some surgeons work with an assistant
endophthalmitis, or other damage. Some patients surgeon in addition to a scrub nurse. During the
have an unusually thin sclera, which makes them immediate postsurgical phase, many doctors ban-
vulnerable to this complication and, of course, dage the operated eye for a short time, usually 1
there s the ever-present possibility of human error. day, to help to prevent infection and to increase
Patients usually want to know about the need for patient comfort due to photophobia. A topical,
reoperation. They often ask whether the results will wide-spectrum antibiotic is usually given for daily
be permanent. In any case, this ssue must be instillation for the first week to 10 days. Conjuncti-
discussed prior to surgery. The possibility of addi- val njection usually disappears in a month or two.
tional operations at some future time depends pri- The frequency of postoperative visits vares widely
man ly on the type and characteristics of the depending on the case and the surgeon, but a typi-
strabismus and the ski 11 of the surgeon. The sur- cal schedule might consist of 1-day, 1-week, and
geon should discuss with the patient his or her suc- 6-week follow-up examinations. After these visits,
cess rate in similar cases. For example, in cases of if no complications develop, the patient s placed
congenital esotropa, Helveston38 informs his on a standard recall schedule or is instructed to
patients that the motor alignment achieved s con- return to the referring doctor for comanagement
sidered acceptable by doctor and parents 90% of (e.g., visin training) and shared responsibility rel-
the time. He also tells his patients that between ative to the strabismus.
10% and 20% of children will need one or more
additional surgical procedures months to years
later for new problems such as secondary exotro- Pharmacologic Treatment
pia, overacting oblique muscles, an A or V pat- Although numerous pharmaceutical agents have
tern, dissociated vertical deviation, or recurrent been used at one time or another for the treatment of
esotropa, even when alignment is perfect after binocular anomalies, those n use today are relatively
surgery. few. Cycloplegics may be used for purposes of occlu-
Some other complications that can occur and that sion. Miotics for accommodative esotropa are some-
may be discussed with patients are (1) post- times used. The two more popular anticholnesterase
operative nausea and vomiting due to anesthesia drugs are diisopropylfluorophosphate (DFP) and
and, possibly, traction on the extraocular mus- echothiophate iodide (Phospholine). These two
cles; (2) acute, allergic suture reaction, which can agents greatly increase accommodation, without a
occur in approximately 10% of cases in which significant increase in accommodative convergence,
organic absorbable suture material is used and for which results in a lower AC/A ratio.
wh'ich top\ca\ steroids are gwen or 7-A O days; Abraham39 p\oneered the use o DFP to reduce
and ^ ptos\s oi lV\e upper e^e\\d Mn\c\\ can esotropva. A. report by GeUman40 summanzed the
occur after excessive recession of the superior effectiveness o DFP by citing case reports \n
rectus muscle) or of the lower eyelid (with large which the nearpoint eso deviation was reduced by
recession of the inferior rectus muscle). use of this drug. However, Phospholine has
Besides learning about the potential complica- become the more popular of these two agents, as it
tions of surgery, patients general ly want to know apparently causes fewer side effects (e.g., forma-
about several other practica! issues relative to the tion of iris cysts) than does DFP. One effect that
operation. In most cases, strabismus surgery is a 1- should always be avoided is the cardiovascular or
day, "in-and-out" procedure. An overnight stay at respiratory failure that may occur when a drug of
the hospital is not usually required, except for gen- this type is combined with those used for general
eral health considerations or when other surgical anesthesia. Bartlett and Jaanus41 emphasized that
procedures are being performed. The patient regis- Phospholine and DFP are very stable complexes
ters with the selected hospital, and standard blood and produce action of long duration. Manley3
Chapter 6 205
warned of the danger of giving general anesthesia acute onset.44'45 The best results tend to occur for
in surgical cases of esotropa when the patient has smaller angles of strabismus and shorter time inter-
previously been taking one of these anticholines- vals between onset and Botox injection.46
terase drugs. If succinylcholine chloride is used Chemodenervation also has a role in cases of sur-
before endotracheal intubation, a drug overeffect gical overcorrection of strabismus (e.g., when an exo-
will occur if the patient has been taking anticho- trope has been converted into an esotrope). Rather
linesterase drugs, and cessation of respiration may than risk another operation, Botox injection serves as
result. A case history should be carefully obtained a conservative opton, and the results are encourag-
to determine whether any such drug was used ng, particularly if there s fusin potential.47'48
within several months of the scheduled time of Botox has been used wth some success in nys-
extraocular muscle surgery. tagmus associated wth esotropa, congental nys-
The use of drugs in the treatment of binocular tagmus, and complex forms of nystagmus. Al I of
anomalies appears to be somewhat limited and these conditions usually require three or four mus-
may be on the decline. There are times, however, cle injections or retrobulbar injections (see Chap-
when their use may be advantageous in the treat- ter 8).49'50 Better visual acuity is usually the result
ment of accommodative esotropa. They may be but lasts for only 3-4 months before further injec-
effective when the AC/A ratio is high, in cases of tions are necessary.
significant hyperopia, and when wearing lenses is Although still controversia!, Chemodenervation
not tolerable. Under most of these circumstances, has been used as an alternative to surgery in cases
it is feasible to prescribe bifocals but, in the case of of developmental comitant exotropia and esotro-
infants and some children, drugs may be a means pa, even infantile esotropa.51'52 In patients older
to reduce an eso deviation. than 18 months, in one study, the overall success
Systemic medications that have generated inter- rate was 58%, which s fairly good for nfantile
est and clinical research lately, such as levodopa, esotropa with abducton nystagmus.53
are designed for use n Parkinson's disease and are Chemodenervation is not nearly as invasive as is
now being tried n the treatment of adult amblyo- extraocular muscle surgery. It often can be per-
pia. However, the results to date provide more formed without general anesthetic for infants
questions than answers. younger than 1 year or patents 6 years of age and
older. A local anesthetic s used, of course, as are
oral sedatives such as diazepam for the very appre-
Botulinum Toxin hensive patient. The needle-electrode s connected
Chemodenervation using botulinum toxin A injection to an amplifer to ensure proper placement in the
is another nonsurgical approach in strabismus man- muscle body; there is a crackling electromyo-
agement that is gaining respect and widening appli- graphic signal when the needle s n position, and
cations. Alan Scott et al.42 developed this procedure then the toxin s slowly injected. Injection s easiest
as a method for weakening extraocular muscle func- n the lateral and medial recti, but the inferior rec-
tion as though a surgical weakening procedure had tus and inferior oblique muscles also can be readily
been performed. The toxin prevens relase of acetyl- accessed. The superior rectus and oblique muscles
choline at the muscle-nerve junction, producing a can be njected, but the levator usually is affected
temporary paralysis of the psilateral antagonist. In by diffusion and produces a full ptosis that can be
right esotropa, the rght medial rectus muscle usually expected to last for 2 months. Henee, the superior
is injected, and for a few weeks, the patent experi- oblique muscle has not proven to be a good site for
ences a rght exotropia that gradually resolves over injection, yielding disappointing results.43
1-2 months to result in a smaller-angle eso deviation. Chemodenervation has many advantages over
The therapeutic effect comes more from the stretch- strabismus surgery, not the least of which is conve-
ing and relaxaton of muscles as they assume a new nience for the doctor and patient.54 The n-office pro-
poston than from any prolonged toxic effects.43 cedure is quick, relatively easy, and less expensive n
Botox, Allergan's form of botulinum toxin A (Dysport comparison to surgery. Botox rarely overcorrects the
injecton, Portn Laboratory Supplies, Salisbury, deviation after the adjustment period. There is less
England), has now proven its worth over the last few chance of infection and serious complications with
years in selected patients. It has been used wth good Chemodenervation. Botulinum toxin A has no sys-
effects in unilateral fourth and sixth nerve palsies of temic side effects when used for strabismus.
206 Chapter 6
Nonetheless, the agent has some negative the binocular visin condition is of psychogenic
attributes that the patient or parents need to know origin (e.g., hysterical amblyopia, or esotropa fol-
and accept before proceeding. Diplopia, some lowing emotional trauma). The professional ser-
spatial disorientation, and a large-angle eye turn vices of a psychologist or psychiatrist may be
can be expected for 1 month or so after successful necessary for resolution of the condition.
injection. A patch can be worn if these results are Hypnosis is an alternative mode of therapy that
intolerable; children usually adapt quickly and has some applications within the field of binocular
well.Transient partial ptosis and a transient vertical visin therapy. Kohn55 stated that visin therapy
deviation are fairly common side effects of even lends itself ideally to hypnosis because it is "focused
horizontal recti injection. In many patients, partic- attention" that helps patients to achieve functional
ularly those with large angles of deviation, mlti- cure. Hypnosis has been used to motvate patients
ple injections are needed to achieve the desired for visin training as well as to increase patient
effect or maintain the result after 4 or 5 years. The acceptance of occlusion, spectacle tenses, surgery,
doctor should wait for 5 or 6 months for complete and many techniques in visin training. Hypnosis
stabilization before reinjecting the same muscle. may be considered in cases of intractable diplopia.
Although rare, there is always the possibility o When one mode of treatment is inadequate,
perforation of the globe; highly myopic eyes are others may be used. It is possible that any combi-
the most vulnerable. Despite these potential draw- nation of the basic methods outlined here may be
backs, in many cases the positive attributes out- employed, and some cases require them all. The
weigh the negative features of chemodenervation, treatment section of this book (Part Two) contains
and so this procedure is gaining in popularity. further discussion of the uses of these treatment
modalities and suggests various combinations in
case studies.
Other Approaches
The doctor must serve his or her patients as a counse-
lor regarding visual health and welfare. Sometimes,
the best interest of the strabismic patient is served by CASE EXAMPLES
doing nothing except monitoring the condition for The previous discussions focused on generalities
changes over time. For example, if the spectacle lens regarding the favorability of various prognostic fac-
prescription is current, the deviation is cosmetically tors. In this section, we present 12 specific cases
and functionally stable, and the patient is satisied that illustrate typical diagnostic groups having a
with the status of the strabismus, then the doctor prognosis for unctional cure ranging from poor to
should not recommend treatment but rather should good. Some clinicians may disagree with our prog-
describe to the patient the condition, its prognosis for nostic judgments because of differences in clinical
long-term changes, and any other practical consider- experience. We tend to be slightly conservative, as
ations. Sometimes patients cannotfollow through on conventional wisdom dictates. A surprisingly suc-
a recommended visin therapy program for several cessful cure after therapy is never unappreciated
reasons and prefer simply to live with the condition by patients. The same cannot be said when thera-
for the time being. The clinician has a duty to peutic results do not match the expectations of
explain, in a sensitive manner, any consequences patients.
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 Poor Prognosis
interest of the patient rather than to promote a partic- Case 1
ularly preerred mode of therapy. The patient is 10 years od with a history of esotro-
The visin specialist must be sensitive to the pa of the right eye since birth. The strabismus has
need for referral when it arises. Many types of stra- been constant since then, although the magnitude is
bismus and other binocular visin conditions can lower now than in infancy. No previous treatment
be subtle indicators of active ocular or systemic has been given. Further history reveis possible trau-
disease. Patients should also be encouraged to matic injury during delivery. Developmental history
seek a second opinin if any questions remain in appears to be normal, other than that the child
the mind of the clinician or the patient. Occasion- always has difficulty abducting the right eye. The
ally, visin specialists examine patients in whom refraction is
Chapter 6 207
surgery should be recommended for cosmetic and, it Vision at near was commensurate with that at far.
is hoped, functional improvement. A contact lens for The deviation is a comitant, constant, unilateral
A A
the right eye may be considered as an alternative to exotropia of the right eye of 25 at far and 15 at
the spectacles at a later time. near with a high AC/A ratio (10/1). Cosmesis is poor
due to the magnitude of the deviation and to a large
Case 3 positive angle kappa (+1.5 mm). The associated
The case history reveis that the onset of esotropa conditions include deep peripheral suppression;
for this 7-year-old patient was at approximately 3 moderate-to-deep amblyopia; unsteady, temporal,
months of age. Examination at age 4 years found a parafoveal eccentric fixation; harmonious ARC; and
refractive error of +0.75-D sphere in each eye. no evidence of motor fusin (i.e., lack of disparity
Lenses of this power were prescribed at that time vergence). No stereopsis response could be elicited.
but were worn only a few days before being This patient has divergence excess exotropia.
rejected by the patient. Present refraction is plano The prognosis for a functional cure of the strabis-
and 20/20 in each eye. mus by means of therapy s poor to fair. The Flom
The deviation is a comitant, constant, alternat- chart would indcate a 30% chance for success
A
ing (right-eye-dominant), esotropa of 15 at far (see Table 6-4). However, the prognosis for achiev-
A
and 13 at near. There is also a large, double-disso- ng a monofixation pattern is fair, and the chance
ciated hyper deviation (dissociated vertical devia- of partally ameliorating the amblyopia is also fair,
tion). The AC/A ratio is normal, and cosmesis s because of the history of intermittence. Some of
good because angle kappa is positive. There s har- the amblyopia may be of extinction rather than
monious ARC and shallow central suppression, arrest. It is unlikely that 20/20 (6/6) visi n will
and the patient has no demonstrable fusin range. be attained, although some improvement can be
The prognosis for a functional cure by means of expected.
any or al I methods of visin therapy is poor. The Assuming the amblyopia can be effectively
Flom chart, however, would indcate a chance of reduced, minus-lens overcorrection may be used
cure of 20-30% (see Table 6-4). The reason for a initially in an attempt to align the visual axes. The
poor prognosis in this case of infantile esotropa is high AC/A ratio is useful for accomplishing this.
that the onset was very early and of long duration. The ARC probably is not as unfavorable as s the
Also, the constant deviation and ARC are negative deep suppression in this case of exotropia. A surgi-
factors, and the dissociated vertical deviation may cal overcorrection (resulting in a small eso devia-
be negative as well. If treatment had been tion) may be called for, both for functional
attempted soon after the onset of strabismus, there outcome as well as for ensuring a good cosmetic
might have been a chance for bifoveal fusin. result in the event visin training fails to effect a
Because there is no cosmetic problem, no treat- functional improvement or cure. It is hoped that
ment should be recommended. Furthermore, onset good fusiona! (disparity) vergences can be devel-
of amblyopia is unlikely to occur, considering the oped and that the patient will at least achieve gross
age of the patient and the fact that the strabismus is stereopsis.
alternating. The patient should be advised to have The patient should be advised that approxi-
a routine follow-up examination in 1 year.
mately 25 office appointments and intensive home
training will be recommended. Surgery may also
Poor to Fair Prognosis Case be needed, and the patient would be given post-
surgical visin therapy.
4
If the parents and the patient do not elect visin
The patient is 10 years od and has a history of training with the possibility of surgery and are con-
exotropia of the right eye that was intermittent, cerned only with cosmesis, an optical approach can
beginning at 7 months through 1 year of age. The A
be tried. A 10 base-in prism can be worn over the
strabismus has been constant since then. Direct dominant left eye. The left eye would then fixate 10
A
patching was attempted for a few weeks at age 3, to the left, and the strabismic right eye would appear
but only token occlusion was accomplished. No straighter, possibly within the cosmetic limit. If, how-
other treatment has been given since. Refraction is
ever, cosmesis remains unacceptable, yoked prisms
A
OD:-1.00 - 1.00 x 180, 20/100 (6/30) may be tried. In this case, a 10 base-out prism
OS: plano, 20/20 (6/6) would be worn over the right eye n addition to the
A
10 base-in prism over the left eye.
Chapter 6 209
Fair Prognosis
Ihepatient is a 5-year-old strabismic with a history Case 6
oconstant esotropa that began at age 2. No pre- The patient s 9 years od and has had a slightly
vious examination or treatment has been given. noticeable esotropa of intermittent onset of the
The present refraction is right eye since the age of 3. The strabismus is occa-
sionally observed by family members when the
Dry retinoscopy:
OD: +2.00 DS, 20/40 (6/12) patient s looking far away. No previous treatment
OS:+1.00 DS, 20/20(6/6) has been given. Refractive history is ncomplete,
Wet retinoscopy (1 % cyclopentolate): but the patient was taken for an eye examination at
OD: +2.50 DS, 20/40 (6/12) age 5. No treatment was given then, and the
advice was that the strabismus would "eventually
OS:+1.50 DS, 20/20(6/6)
go away." The present refraction is
The deviation s a comitant, constant, unilat-
Dry subjective:
eral esotropa of the right eye of 10A at far and 20A
OD: +1.00 DS, 20/30 (6/9)
jt near with a high AC/A ratio. Cosmesis s good
OS:+1.00 DS, 20/20(6/6)
because of a large positive angle kappa (+1.5
Wet subjective (1 % cyclopentolate):
mm). The associated conditions include deep
OD: +1.50 DS, 20/30 (6/9)
suppression; shallow amblyopia; nasal, inferior,
OS: +1.50 DS, 20/20 (6/6)
unsteady, paramacular, eccentric fixation; and no
fusional (disparity) vergence. Correspondence s Vision at near was commensurate with that at far.
normal, and there is no evidence of horror fusio- The deviation s a comitant, intermittent (con-
nis. Neither gross or fine stereopsis could be stant at far and estimated 75% of the time at near),
elicited. unilateral esotropa of the right eye of 15 A at far
This patient has convergence excess esotropa. and 4A at near. Cosmesis s good because of a pos-
The prognosis for complete functional cure is poor itive angle kappa and a relatively wide IPD of 65
to air. The Flom chart would indcate a prognosis mm. The AC/A rato is low (2/1). Associated condi-
of 30% for success (see Table 6-4). However, the tions include ntermittent, deep, central suppres-
prognosis for a partial cure, whereby a monofix- sion; shallow amblyopia; small (foveal off-center)
ation pattern is to be achieved, is fair to good. The nasal eccentric fixation; harmonious ARC (covaria-
chief reason that a complete cure (in which there is tion at near); and good second-degree fusin but
exact bifoveal fixation) is diffcult to achieve in this limited motor range. Some peripheral stereopsis
case is that the duration of constant strabismus is 3 was occasionally elicited at near.
years. This patient has a divergence insufficiency
There are many cases in which regaining esotropa. The prognosis for functional cure by
bifoveal fixation s difficult after the patient has means of therapy s fair. The Flom prognosis chart
lost it for a relatively long period of time. This s would indcate a 50% chance for functional cure
particularly true n very young patients. (see Table 6-4). Although there is deep central sup-
In this case, however, the prognosis for cure of pression, the factor of ntermittence helps the prog-
amblyopia by means of constant occlusion, pleop- nosis immensely. The primary purpose of visin
tics, and other monocular training activities is therapy in this case is to improve the presently
good because of the patient's young age and rela- existing visual skills that are at play at least some of
tively late onset of the amblyogenic strabismus. the time at near distances. Binasal occlusion for
The patient should be advised that bifocal spec- farpoint seeing may be tried, as well as the possi-
tacles lenses will be necessary and that approxi- bil ty of base-out prisms, followed by antisuppres-
mately 25 weekly office training sessions, along sion training and the development of adequate
with home training, are needed to develop periph- fusional divergence. A certain amount of training
eral fusin and good fusional vergence ranges. to improve monocular fixation and accommoda-
Because cosmesis is good and functional results tive facility would be helpful prior to the binocular
can be expected without surgical intervention, therapy rgimen.
there s probably no need for an operation n this The prognosis must remain somewhat guarded
case. However, prisms may be required during and because of the long duration of strabismus and
after visin training. lack of previous treatment. The patient should be
210 Chapter 6
with far fixation but is noticeable at times with The patient should be advised to make 5 weekly
near face-to-face viewing. NRC s present. Associ- office appointments for visin therapy and to plan
ated conditions include shallow central suppres- on home training for approximately 30 minutes
sion when the deviation is manifest; fixation per day during this time. Afterward, 5-10 minutes
disparity (associated exophoria of 1A at far and 5A per day of continued home training may be recom-
at near); and poor motor fusin ranges. Stereoacu- mended as a home maintenance program, until a
ity is approximately 60 seconds are at far and near progress evaluation s conducted n 4 months.
during fusin.
The prognosis for a functional cure by means of
lenses and visin therapy is good90% according REFERENCES
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on Strabismus, Transaction of the New Orleans Acad-
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Optometric Center of New York; 1969:18.
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14. Chavasse FB. Worth's Squint, 7th ed. Philadelphia: Blaki-
The prognosis for a functional cure by means of ston's; 1939.
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37:630-631.
fort and the inadequate nearpoint of convergence. 17. Costenbader FD. Diagnosis and clinical significance of
(Note that in cases of strabismus in which the the fusional vergences. Am OrthopJ. 1965;15:14-20.
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binocular visual skills and, it is hoped, to enhance 19. Griffin JR. Efficacy of visin therapy for nonstrabismic ver
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binocularity for efficient visual skills.)
Chapter 6 213
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lar Motility: Theory and Management of Strabismus, 6th Optom. 1963;40:93-101.
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mus. New York: Grue & Stratton; 1982:340-381. 42. Scott AB, Rosenbaum AL, Collins CC. Pharmacological
25. Jampoisky A. A Simplified Approach to Strabismus Diag weakening of the extraocular muscles. Invest Ophthalmol
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Mosby; 1971:34-92. Therapy: Technque and Indcations. In: Clinical Strabis
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the International Strabismological Association. Fells P, ed. toxin in fourth nerve palsies. Aust NZ J Ophthalmol.
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pa: a case report. AmJ Optom. 1948;25:80-91. by botulinum type A toxin. Nippon Ganka Cakkai Zasshi.
28. Postar SH. Ophthalmic Prism and Extraocular Muscle 1999;103:112-118.
Deviations: The Effect of Wearing Compensatory Prisrns 46. Quah BL, Ling YL, Cheong PY, Balakrishnan V. A revew
on the Angle of Deviation in Cases of Esotropa. Snior of 5 years in the use of botulinum toxin A in the treatment
research paper. On file in the M.B. Ketchum Memorial of sixth cranial nerve palsy at the Singapore National Eye
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29. Crter DB. Effects of prolongad wearing of prism. Am J toxin A in surgically overcorrected exotropia. J AAPOS.
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In: Symptoms on Strabismus, Transaction of the New botulinum toxin in consecutive and secondary exotropia:
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operative extraocular muscle suture adjustment with its hood Strabismus. Strabismus. 1999;7:103-111.
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Strabismus Q. 1999;14:277-284. delayed botulinum toxin injection in esotropa in the
34. Rosenbaum AL, Metz HS, Carlson M, et al. Adjustable child as first line treatment. J Fr Ophthalmol. 1998;21:
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Ophthalmol. 1977;95:817. 53. Ruiz MF, Moreno M, Snchez-Garrido CM, Rodrguez
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BrJ Ophthalmol. 1999;83:788-791. 2000;37:196-205.
36. Spierer A. Adjustment of sutures 8 hours vs 24 hours after 54. McNeer KW. An nvestigation of the clinical use of botuli
Strabismus surgery. Am J Ophthalmol. 2000;129:521- num toxin A as a postoperatve adjustment procedure in
524. the therapy of strabsmus. J Pediatr Ophthalmol Strabis
37. Siegel LM, Lozano MJ, Santiago AP, Rosenbaum AL. mus. 1990;2 7:3-9.
Adjustable and Nonadjustable Recession and Resection 55. Kohn H. Clinical hypnosis as an adjunct in visin therapy.
Techniques. In: Clinical Strabismus Management. Rosen- Optom Monthly. 1983;74:41^4.
chapter 7 / Types of Strabismus
begins with the characteristics of accommodative alous retinal correspondence (ARC), or a microtropic
esotropa and an overview of management when the component can develop. Older children may report
mechanism is primarily accommodative, causing intermittent diplopia, blur, and eyestrain, particularly
excessive accommodative convergence. when performing near tasks. In some cases of high
uncorrected hyperopia (e.g., more than 6 D), the eyes
may remain straight much of the time when the indi-
Refractive vidual s not using accommodation; however, the
Accommodative Esotropa consequence may be bilateral amblyopia (i.e., isome-
Characterstics tropic amblyopia) if the retinal images remain blurred
Both types of accommodative esotropa usually occur most of the time. Characteristics of accommodative
between the ages of 2 and 3 years, concurrently with esotropa (refractive and hgh AC/A types) are listed n
the development and ncreased use of accommoda- Table 7-1.
tion. However, the range of onset is broad, extending
from nfancy into young adulthood.1 The strabismus Management
can become manifest with illness, extreme emotion, ptica! Treatment
or eye fatigue. The etiology of refractive accommoda-
tive esotropa is better understood than that of al I With early treatment, the prognosis is good for com-
other developmental types of strabismus. Modrate or plete resolution of the strabismus, particularly f nor-
high uncorrected hyperopia, usually between 2 and 6 mal binocularty existed prior to the onset of the
diopters (D), forces an individual to accommodate deviation. Usually all that is necessaty is a prescrip-
sufficiently to attain clear retinal images. An average tion of lenses for the ful I optical correction of the
hyperopia of +4.75 D was reported for accommoda- uncorrected hyperopia (and any significant astigmatic
tive esotropes.2 There is usually a normal AC/A ratio, component) as verified by cycloplegic refraction (Fig-
but excessive accommodation, which is required to ure 7-1). The goal of optical treatment is not necessar-
overeme the hyperopia, evokes excessive conver- ily orthophoria. Some authorities recommend leaving
gence. If compensating fusiona! divergence is insuffi- the patient slightiy esophoric so that there is a con-
cient, a latenteso deviation becomes manifest, dueto tinuing demand for fusional divergence. 3 If the
the combination of uncorrected hyperopia and inad- patient's accommodation does not relax fully after the
equate fusional divergence ranges. The onset of prescription lenses are worn for a few days and if
accommodative esotropa is usually gradual and there is significant blurred farpoint visin, the doctor
intermittent. Because of its intermittent nature, there should also recommend accommodative rock train-
is usually normal retinal correspondence (NRC) ing or administer a cycloplegic drug (atropine) if
and seldom any amblyopia. If the manifest deviation absolutely necessary. The purpose would be to
becomes constant at an early age, amblyopia, anom- reduce an accommodative spasm. Occasionally,
Chapter 7 217
Management
Optical Treatment
be programmed to elimnate amblyopia and sup- DFP is the most effective miotic and is associated
pression and then to develop and improve fusiona! with less systemic absorption. However, Pl is readily
divergente. Adequate fusional vergences serve to available in different concentrations and, therefore,
improve control of the deviation at all viewing dis- has greater versatility in clinical management. DFP
tances, which is important because the deviation often s preferred for preschool children and Pl for
vares n magntude from far to near. (See Chapter older children and adults. The miotic agent s given
13 for visin training techniques.) Without adequate one time daily often at night, before sleep.
visin training, these patients tend to lose control of Clinicians must be aware of the complications
the deviation at near, and suppression can recur at associated with the use of miotics (anticholinester-
near fixation distances. The higher the AC/A ratio, ase agents), some of which are serious. The most
the more a patient tends to lose control of the devia- hazardous complcatin occurs when a patient tak-
8
tion over time. We do not recommend combining ng topical miotics is given a depolarizing muscle
miotic therapy with a visin training program. relaxant, such as succinylcholine, during general
Although some clinicians may disagree, our experi- anesthesia. This drug combination can result in a
ence indicates that visin training progress s erratic prolonged, even fatal, apnea. Consequently, patients
when miotics are used simultaneously. It s unclear taking a topical miotic should carry a card clearly
why this s so, but results are better when one or the identifying its use, in case of emergency surgery. A
other therapeutic method s applied alone. patient should discontinu the use of miotics for at
least 6 weeks before succinylcholine can be used
Miotics safely. Another potentially fatal mistake s the oral
ingestin of topical miotics. These agents must be
If the nearpoint deviation cannot be adequately con- kept securely out of the reach of children. Death is
trolled using bifocals and visin training, miotics may caused by a cholinergic crisis resulting from block-
be considered as a treatment option. We believe that age at motor end plates of the heart and lungs.
topical anticholinesterase drugs have been overused Although uncommon, serious systemic toxicity
n the treatment of accommodative esotropa. resulting from the use of miotics has been reported,
Because they have significant side effects and do not manifesting in the gastrointestinal system as nau-
9
offer a long-term solution, t seems prudent to try to sea, abdominal discomfort, and diarrhea. Manual
control the near deviation by other means, if possi- depression of the lacrimal canaliculi during and
ble. Miotics, however, may be effective initially to after topical administration should prevent, or min-
achieve temporary ocular alignment when other imize, these systemic side effects.
methods have failed. Introducton of more conserva- The most common ocular side effect is the devel-
tive visin therapy methods for long-term manage- opment of iris cysts at the pupillary margin, which
ment of the deviation can then be made. occurs n approximately 50% of children taking Pl.
Common anticholinesterase eye drops such as The cysts can grow large enough to obscure visin,
diisopropylfluorophosphate (DFP 0.025% ointment) but these usually are reversible by discontinuing the
and echothiophate iodide solution (Phospholine use of the miotic. The development of such cysts
lodine [Pl], 0.03%, 0.06%, or 0.125%) produce an can be minimized by instilling a drop of 2.5% or
accumulation of acetylcholine at the myoneural 10% phenylephrine (Neo-Synephrine) concurrently
junction of the ciliary muscle. This acetylcholine with the miotic. Iris cysts occur less often as a side
buildup results in a decrease in the innervation nec- effect with the administration of DFP than with Pl.
essary for effective accommodation and, therefore, Miotics cause other ocular side effects includ-
n a corresponding decrease of accommodative con- ing ciliary spasm with brow ache, conjunctival
vergence. Vergence is effectively decoupled from injection, and iritis. These are usually transitory,
accommodation, so an increasing eso deviation at but more serious complications can occur such as
near does not occur with accommodative effort. An angle-closure glaucoma, retinal detachment, and
additional factor responsible for the reduction of anterior subcapsular cataracts (usually reversible
accommodation and accommodative convergence in children). Because of these possible side effects,
is the miosis itself. Small pupils increase the depth of we recommend the initial use of optical treatment
focus so that near objects can be seen clearly with and visin training techniques rather than miotics
much less accommodation than s needed by nor- n most cases of high AC/A accommodative
mal-sized pupils. Of the two commonly used agents, esotropa.
220 Chapter 7
accommodative-convergence/accommodation.
increasing hyper deviation of an eye as it moves abnormal head posture n an unconscious attempt
nasally during versions. The other eye is similar as to dampen the nystagmus. Lang21 proposed that
this inferior oblique overaction is usually bilateral. the reason nystagmus and DVD are associated
In one series of 408 infantile esotropes, overaction with infantle esotropa s the presence of a mid-
of the inferior oblique muscles was found n 68% brain lesin disrupting both vestibular and oculo-
of the sample.20 For unknown reasons, the condi- motor control centers.
tion usually is not present during the first year of There are only a few reported cases of nfantile
life but appears later in childhood. esotropa that have apparently resolved spontane-
Another poorly understood condition associated ously without treatment. 22 These were patients
with infantile esotropa is dissociated vertical devi- who presented with relatively small angles of devi-
ation (DVD), which must be distinguished from ation before 6 months of age but who, at ages 3-5
bilateral overacting inferior oblique muscles in years, showed small phoric deviations. However,
young children. DVD is also known as double binocular visin remained compromised (i.e., little
hyper. On cover testing, either eye that is covered or no stereopsis and DVD).
drifts upward; when it is uncovered, a downward
movement is observed (i.e., either eye is hyper on
the cover test) (Figure 7-5). This s the opposite of
Management
the usual hyper-hypo relationship seen n most ver- A cardinal principie n the management of nfan-
tical deviations. One eye may show a larger hyper tile esotropa s early ntervention. Generally, the
deviation than the other, which suggests the pres- longer effective therapy s delayed, the worse s the
ence of an ordinary hyper deviation component long-term prognosis (see Chapter 6). The ideal time
that s obscured by the double hyper. at which to initiate visin therapy is at the onset of
In contrast to overacting inferior oblique mus- the condition. Prognosis for a functional cure of
cles, DVD is usually evident in all fields of gaze. very early nfantile esotropa approaches zero f
The prevalence of DVD n nfantile esotropa s treatment is delayed beyond the age of 2 years.
hgh, ranging from 51% to 90% depending on the Early treatment is not merely important; t s essen-
patent series.20'21 The onset of DVD is usually after tial. Another principie s frequent examinations of
age 2 years, and t may occur years after successful the child, because the visual status can change
surgical management of the esotropa. It is advs- dramatically and rapdly during the first few years
able to discuss this possibility with the patient's of life. General principies of clinical management
parents so that, f DVD should occur in the future, are as follows.
t would not be completely unexpected. It is note-
worthy that we have seen DVD n orthophoric (or Optical Treatment
nearly orthophoric) patients who have normal bin- Corrective lenses to cover ful I cycloplegic, retino-
ocularity in all other respects. scopic findings should be prescribed if there is a
Another fairly common feature of nfantile significant refractive error. Spectacle lenses are
esotropa s nystagmus, both latent nystagmus and intended to correct any accommodative compo-
manfest nystagmus with a latent component. nent of the deviation as well as any significant
Reported prevalences range from 25% to 52% astigmatism or anisometropia. Prescription for
dependng on the particular patient series.20'21 even small amounts of hyperopia s warranted if
Many nystagmus patents with esotropa have an the lenses are intended also to provide a platform
Chapter 7 223
on which to mount Fresnel prisms. The prism practically with prisms (greater than 20A), surgery s
power should be equal to or greater than the necessary before the age of 2 years to ensure a rea-
amount of the residual deviation. Prism spectacles sonable chance for normal binocular visin. In a now
should be worn at least 3 hours daily in an attempt classic study, Taylor23 demonstrated the advantage of
to provide normal binocular stimulation during the early surgical ntervention (see Chapter 6). Subse-
critical developmental period. This therapeutic quent studies have also confirmed this advantage but,
method should be attempted prior to any neces- even so, the best result that can be expected in many
sary surgical intervention. Retinoscopy should be cases appears to be peripheral, but not central,
repeated at least every 3 months during the first 2 fusin. Often there remains a microtropia (monofix-
years of life, as changes n refractive status can ation syndrome or, more properly, monofixation pat-
occur frequently and rapidly. tern), reduced stereopsis, and ARC. Nevertheless,
there may be fairly good motor vergence ranges.
Vision Training Normal stereoacuity should not be expected n many
cases of nfantile esotropa.
Vision training should begin with monocular occlu-
Figure 7-3 depicts a case of infantile esotropa
sion. Even in cases of no amblyopia, patching
that was present at birth; the photograph shows a
ensures that amblyopia will not develop. Appropri-
large constant deviation at age 4 months.24 At age
ate patching builds monocular fixation, prevents
13 months, ths baby grl underwent bilateral
suppression and the development of ARC, and pro-
medial rectus and lateral rectus resections. At age
motes abduction. Other than at those times when
2.5 years, penalizaron (attenuation) therapy with
the infant is wearing prism spectacles for binocular
atropne was given to treat amblyopa of one eye.
stimulation, patching should be constant if there is
By age 6, the visual acuty of the amblyopic eye had
constant esotropa. If the strabismus s intermittent
improved from 20/60 to 20/30, at which time visin
(a rare occurrence in cases of infantile esotropa),
training techniques were initiated and continued for
patching should be intermittent during those times
2 years. At age 11, the patient's visual acuities were
that the patient is likely to have a manifest deviation
20/20 and 20/25, but there was constant 20A unilat-
(e.g., fatigue n afternoons or evenings). Care must
eral exotropia at far and intermittent 20A exotropia
be taken to avoid occlusion amblyopia when patch-
at near, DVD, covarying retinal correspondence
ing a patient younger than 5 years. Infants younger
with intermittence of the exotropia, shallow sup-
than 2 years should receive daily altrnate patching
pression, and no stereopsis. After 1 year of visin
even n cases of unilateral amblyopia. (Refer to
training, stereoacuity varied from 50 to 200 seconds
Chapter 10 for a discussion of occlusion.)
of are on contoured targets, but there was no stere-
Parents and caregivers should be instructed about
opsis on noncontoured (random dot) testing. The
active stimulation of fixation and abduction of the
unilateral cover test revea I ed 2A of esotropa, n
child's strabismic eye. To build fixation and eye-
which the exo deviation was latent most of the time.
hand coordinaron skills, small toys, candies, and
The angle of anomaly on the Cppers bfoveal test
other objects can be offered to the child to touch,
was approximately 2A, which suggested harmonious
while the child's dominant eye is patched. To stimu-
ARC centrally, although peripheral sensory and
late abduction, interesting and desired objects can
motor fusin seemed normal, which probably kept
be slowly introduced into the child's restricted field
the exo devation latent. Best corrected visual acu-
of gaze. However, many visin training techiques
ities were 20/20 and 20/25+. Although not com-
for building binocularity are not practical for chil-
pletely cured, this patient with congenital esotropa
dren younger than 2 years. The goals of visin train-
was able to achieve a satsfactory monofixaton
ing, however, are to establish equal and normal
pattern with the help of several modes of visin
visual acuity, free alternation of the eyes (to prevent
therapy.
recurrence of amblyopia), and good ocular motility.
Although considerable disagreement exists among
The next step s eye alignment to promote develop-
surgeons, there appears to be little advantage for a
ment of normal binocular visin.
successful outcome in performing surgery n patients
younger than age 1.2S In addition, the risks of general
Surgery anesthesia may be enhanced in this very young pop-
tthe residual angle of deviation after full correction ulation. The patient should maintain a patching rgi-
of the refractive error is too large to be managed men until age 1, which, in our opinin, seems to be
224 Chapter 7
deviation is usually between 20A and 70A, and the other problems that adversely affect the prognosis
magnitude may slowly ncrease over time. Refrac- for later mprovement.
tive error often is ndependent of the onset of the The surgical approach in PCE usually relies on
deviation, because many affected patients have lit- recession and resecton procedures. Adjustable
tle or no ametropia. However, there can be a par- sutures frequently are used to fne-tune the surgcal
tially accommodative component to the strabismus results on the day of, or after, the operation. Also,
that requires optical compensation. botulinum toxin injections nto the medial recti to
The cause of PCE is believed to be a develop- weaken them sometimes are used n older children
mental innervational anomaly, possibly a multifac- and adults. (Detailed discussions of visin therapy
torial genetic trait, but the specific pathogenic for eso deviations are provided in Chapter 13.)
mechanism is unknown. A small number of PCE The immediate postsurgical goal is to position
cases orignate from a supranuclear tumor that the eye slightly on the esotropic side of straight
may be life-threatening.30 In most tumor cases, alignment, approximately 10 A eso, because the
however, the deviation is noncomitant and con- eyes typically diverge with healing. The best long-
spicuous. The clinician must be a very conscien- term results are found in cases that show ortho
tious observer in cases of strabismus that develop alignment or a small eso deviation 1 month post-
early in life, to ensure immediate detection. operatively. The worst stability occurs in patients
Most cases of PCE are basic eso deviations, showing consecutive exotropia at the 1-month
which means they are characterized by a normal checkup.32
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 PRIMARY COMITANT EXOTROPIA
eso deviation s significantly less than that at far. It
Under the Duane-White classification of primary
is important for the clinician to distinguish DI from
comitant exotropia (PCX), there are three sub-
divergence paralysis, which has serious neurologic
implications. Divergence paralysis originating classes: basic exo deviation (BX), divergence
excess (DE), and convergence insufficiency (Cl).
from a midbrain lesin often presents with a
greater eso deviation at far than at near, as in DI. This simplified classification is based on the far-
However, the deviation is usually noncomitant ini- point deviation n relation to the AC/A ratio. (See
Chapter 3, as these classifications also apply to
tially but may gradually evolve toward comitancy
heterophoria.)
over time. This feature can complcate the differen-
tial diagnosis between dvergence paralysis and
DI. Therefore, clnicians should closely monitor all Characteristics
new patients presenting with characterstics of DI. PCX has an etiology similar to that of PCE, an
Neurologic examination and neuroimaging can innervational anomaly probably of multifactorial
usually be deferred in the inital presentation of genetic origin. Table 7-4 lists some of the features
low AC/A esotropa that s associated wth farpoint of PCX. This condition is less prevalent than PCE
diplopia, unless there are other neurologic signs or (approximately 33% as frequent) and reportedly
symptoms.1'20 occurs more often in girls than n boys (66% more
frequent) for unknown reasons.33-34
Unlike esotropes, most exotropes are intermittent
Management (approximately 80%) throughout life. Jampolsky35
Prognosis s generally good in cases of PCE if pointed out that the progression of exotropia is usu-
there s early intervention with visin therapy ally gradual, starting with an exophoria, then evolv-
(often including surgery). The later the onset of ing to an intermittent strabismus, with only a small
PCE, the better s the prognosis. Lang31 reported portion of patients becoming constant exotropes.
that an onset of PCE after 1.5 years of age indi- He suggested that suppression s the mechanism of
cates a good prognosis after surgical alignment; decompensation from exophoria to exotropia.
many patients can develop good random dot ste- Infantile presentations of exotropia, before age 6
reopsis. If visin therapy s delayed, however, months, are very rare (1 in 30,000) as compared
patients often develop amblyopia, ARC, suppres- with infantile esotropa (0.5-1.0%).36 Nevertheless,
sion, increased magnitude of the esotropa, and these few cases are not usually referred to as nfan-
226 Chapter 7
Ihese patients have simulated (pseudo) divergence For ths reason, it is often advisable to examine
oecess. We believe this is nearly as prevalent as patients with intermittent strabismus late in the
rudivergence excess. Any patient presentng day, for comparison with results found earlier n
th a larger exo deviation at far than at near the day.
should be patched to break down any spasm of Over time, there is a tendency for intermittent
Misional convergence, which can mask the true exotropia to worsen; the condition s usually pro-
agnitude of the deviation at near. The examiner gressive. von Noorden16 followed up 51 young
must take care not to allow any binocular fusin patients with intermittent exotropia for an average
betore the nearpoint angle is remeasured. The of 3.5 years without treatment; 75% of the cases
cover paddle should be placed before the patient's were found to worsen, often becoming a constant
occluded eye as the patch is removed. If the near- deviation. No change occurred n 9%, and 16%
point deviation is not influenced by occlusion, the improved without therapy. The practitioner needs
patient can be considered to have true divergence to take this into consideraron when making rec-
cess and should be treated accordingly. Another ommendations for treatment. When feasible, we
test used to identify simulated divergence excess vs
c\a\\Y \v\tY\ visin training, as soon as the condition
near s remeasured with plus sphere lenses in is identified.
place (+2.00 D s recommended) to fnd the gradi-
X\Q. "\V\\s ^&\<
: \es\Yvr\d\xvg:, for tax and near. \\ tVie ca\cu\ated Vxo%nos\s for recoverv oi binocuAar unction \n
AC/A ratio is high and the gradient ratio is rela- exotropia is good in patients who experience a
tively low, then the implication is simulated diver- long period of intermittence, as compared with a
gence excess. However, if the calculated and child who has a constant deviation from early
gradient AC/A ratios prove to be high, true diver- childhood. Amblyopia is relatively rare in PCX
gence excess is indicated. For example, if the cal- unless there s significant anisometropia. Likewise,
culated AC/A is 10/1 and the measured gradient ARC is not a serious clinical problem, because the
AC/A is 7/1, both are considered to be high and angle of anomaly can covary with the magnitude
the difference between them is as expected for the and intermittence of the exo deviation. (See the
two different procedures. Thus, a true divergence discussion of covariation of correspondence in
excess is indicated. However, if the calculated AC/A Chapter 5.)
ratio is 10/1 and the gradient test measures 4/1, the In our experience, if the angle of deviation in
difference between the two is relatively large, and PCX s less than 20-25A, our preferred treatment
simulated divergence excess is indicated. When- option is visin training, provided the patient is
ever simulated divergence excess is suspected, a mature enough to particpate actively in the pro-
prolonged cover test should be performed, as it is gram. For larger deviations, we recommend begin-
the definitive diagnostic procedure for far and near ning with a visin training approach but expect
deviation measurements. that surgery may be necessary to achieve comfort-
Another important clinical feature of intermit- able alignment of the eyes at all distances and
tent exotropia is variable diagnostic findings, day times of day. The surgical principies in PCX depend
to day and hour to hour. The amount of fusional not only on the magnitude of the strabismus but
vergence available to compnsate for a deviation also on whether the deviation is a basic exo devia-
vares from time to time depending on a given tion, divergence excess, or convergence insuffi-
patient's state of fatigue, alertness, and general ciency (see Chapter 14).
health. Patients tend to lapse nto their exotropc
deviation when inattentive, daydreaming, or gaz-
ing at the ceiling or sky. The time of day of the A AND V PATTERNS
visual examination can influence the measured The terms A and V patterns are used to describe
clinical features of the condition. Early n the day, significant changes in the horizontal deviation (eso
the patient may present with exophoria with excel- or exo) as the eyes move from up-gaze to the pri-
lent stereopsis, whereas n late afternoon, the same mary position to down-gaze. A and V patterns are,
patient may have exotropia with deep suppression. therefore, a form of noncomitancy of the horizon-
228 Chapter 7
a.
c. d.
tal deviation. Specifically, an A pattern is present more between up- and down-gaze. However, a V
when there is an increased convergence (or less pattern s indicated when there is 15 A or more
divergence) of the eyes in up-gaze and increased change vertically. This larger measurement crite-
divergence in down-gaze. If a patient has an A- rion for V patterns s attributable to a physiologic
pattern esotropa, the eso deviation increases in tendency for relative divergence in up-gaze.
up-gaze and decreases in down-gaze, whereas in In addition to A and V patterns, some patients
A-pattern exotropia, there is decreasing exo devia- may show an X pattern, n which divergence
tion in up-gaze and increasing exo deviation when increases in up- and down-gazes (e.g., exotropia in
looking down (Figure 7-6). Conversely, a V pattern both up- and down-gaze). This might be due to
is indicated when the visual axes diverge in up- overaction of inferior and superior oblique muscles,
gaze and converge in down-gaze. The V-pattern causing a combination of a V and an A pattern.43
esotropa increases in magnitude in down-gaze, Estimates of the prevalence of A and V patterns
whereas a V-pattern exotropia increases in up- vary widely, depending on the source and diagnos-
gaze. These changes in the horizontal deviation tic criteria. Prevalence s probably cise to half of
with vertical gaze changes are clinically important all strabismic patients.44 The relative frequency of
because they significantly influence the diagnosis, these patterns, from most prevalent to least, is as
prognosis, and management of strabismus. follows: (1) V-pattern esotropa (by far the most
prevalent), (2) A-pattern esotropa, (3) V-pattern
exotropia, and (4) A-pattern exotropia.45 The V pat-
Characteristics terns occur approxmately twice as often as do A
An A or V pattern is diagnosed by comparing the patterns, probably because esotropa is more prev-
altrnate cover test results in the primary position alent than exotropia.
to those found in the extreme up and down posi- The etiology of A and V patterns is usually not
tions of gaze. By convention, an A pattern is indi- paresis but mechancal in nature. The principal
cated if the horizontal deviation changes 10A or factors seem to be overactions and underactions of
Chapter 7 229
the oblique and vertical rectus muscles. For exam- nique depends, of course, on the observed patterns of
ple, the most frequent cause of a V-pattern esotro- over- and underaction of the vertically acting mus-
pa is the underaction of one or both superior cles. For example, if there is also overaction of the
oblique muscles. In down-gaze, the eso deviation superior oblique muscles n an eso A pattern, weak-
is increased by the loss of abduction by the under- ening procedures for these oblique muscles may be
acting superior obliques. In up-gaze, the eso devi- necessary. An underaction of the inferior obliques
ation s decreased by the relatively increased may also aggravate an A pattern and may require
abduction by the normally acting or overacting strengthening procedures. V-pattern esotropas may
inferior obliques. Anatomic abnormalities of the require recession of both medial recti and downward
bony structure of the orbit and abnormal insertions displacement of the original insertion. Because
of muscle tendons have been cited also as etio- underaction of the superior oblique muscles will
logic factors in producing an A or V pattern.11 A mercase a V pattern, these muscles may require
and V patterns are frequently associated with strengthening procedures. Similarly, overaction of the
infantile strabismus, Duane retraction syndrome, inferior obliques exacrbales a V pattern and may
Brown syndrome, acquired bilateral fourth nerve require weakening procedures.
palsy, dysthyroid eye disease with inferior rectus A-pattern exotropia may require recession of
muscle contracture, and orbital malformations both lateral recti, with downward displacement of
found in Down syndrome. On the sensory side, the insertions. If the eyes are exotropic with an A
ARC can occur in strabismic patients with A and V pattern due to an overaction of the superior
patterns; however, as the horizontal angle of devia- oblique muscles, weakening procedures for these
tion (H) changes n up- and down-gaze, the angle may be required. V-pattern exotropias may be
of anomaly may covary with it. treated by recession of both lateral recti, with
If a strabismic individual can achieve normal upward transposition of the insertions. If the infe-
fusin in some field of gaze, that person usually rior oblique muscles are overacting, the exo devia-
adopts a head posture that allows fusin to occur. tion tends to increase on up-gaze; these, therefore,
la patient presents with a habitual chin elevation may require weakening procedures.
or depression, A and V patterns should be sus- Vision training s often helpful n cases in which
pected. For example, a V-pattern esotrope who can the patient has some fusional vergence ranges, partic-
achieve fusin n up-gaze may present with a chin ularly in exotropic cases that are intermittent. When
depression and a "mischievous" appearance, the exo deviation is small or modrate in the primary
whereas a V-pattern exotrope may display chin position, visin training has great valu. However, in
elevation and a "snobbish" appearance, because cases of large exo deviations with V patterns, surgery
the deviation s reduced n down-gaze. may be necessary. Otherwise, when the patient looks
up to the sky or ceiling, where there are minimal
environmental contours to stimulate fusin, the exo
Management deviation will likely manifest.
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 up- MICROTROPIA
gaze. Clinicians can test for A and V patterns at either The definition of microtropia is disputed, and clini-
far or near distances, whichever they prefer. cians disagree as to its characteristics. The terms
Significant A and V patterns can often be treated microstrabismus, monofixation pattern (or syn-
surgically, usually by either operating on the oblique
drome) , and subnormal binocular visin have al I
muscles or transposing the horizontal rectus mus-
been used to refer to the same or similar condi-
cles.43 Surgical correction of an A or V pattern is indi-
tions. Microtropia s our term of choice for the
cated if the vertical noncomitancy contributes to condition having the characteristics described in
excessive fusiona! demands or unacceptable cosme- the following section.
sis 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 Clinical Characteristics
transposed above the original nsertion, approxi- We believe that manifest deviation must be 1A or
mately a muscle-width. The specific surgical tech- greater in magnitude to be classified as strabismus.
230 Chapter 7
Mechanism
Unknown, often secondary to sur-
gery or visin training for an
Infantile or prmary comitant
esotropa
Onset Fronn birtn or the time of therapeu-tic
intervention
Refractive error Probably no relationship
Deviation 1-9A strabismic component; usually an
additional phoric component; eso
deviations much more com-mon
than exo or hyper deviations
Constancy Usually constant in all fields of gaze
and at all fixation distances
Comitancy UsuaHy comitant
Correspondence Usuatly anornalous retina! corre-
spondence 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 FIGURE 7-7Microtropia of the right eye as shown on the altrnate
Symptorm Poor for bifoveal fusin; usuaity a stable cover test. a. Cosmetically good n primary position. b. Occluder on
right eye and no movement of the eyes. c. Occluder on left eye and
Prognosis end-stage condition
movement of both eyes. d. Occluder switched to the right, esotro-
pic eye and movement of both eyes, with left eye resuming fixa-
tion. e. Occluder remaining on right eye for approximately 1
minute, after which right eye slowly moved more inwardly, indicating
a "phoric" component to the esotropa.
A fixation disparity, however, s much lower in mag-
nitude, usually not exceeding 20 minutes of are.
(See the discussion of fixation disparity in Chapter sion of the deviated eye. Nevertheless, fusional ver-
3.) In our opinin, microtropia has been errone- gence ranges can be measured and sometimes are
ously described by some clinicians as an "unusually almost normally sufficient. Usually there is ARC that
large fixation disparity." We prefer to use the term is harmonious relative to the strabismic component
mcrotropia to describe a frequently seen condition of the deviation. Similarly, there may or may not be
that has most of the characteristics usted in Table 7-5. amblyopia. Peripheral stereopsis often is present,
There is a manifest deviation on the unilateral cover but central stereopsis is absent or greatly reduced,
test from 1A to approximately 8A or 9A. This angle especially with random dot targets.
may show some variability in magnitude. Besides There are two major types of microtropia, pri-
the manifest deviation, there is often a latent devia- mary and secondary. Primary microtropia is indi-
tion (a phoric component) seen on the altrnate cated if there is no history of a larger angle of
cover test. On this test, one eye or the other s strabismus. The etiology of this condition is
always being occluded, which reveis the fusion- unknown but, like PCE, there appears to be some
free deviation. Clinically, the results of the unilateral genetic basis. Secondary microtropia is often the
cover test are compared with those from the altr- result of visin training or surgery for a larger angle
nate cover test. A larger magnitude is frequently of strabismus, particularly in cases of early onset.
seen on the altrnate cover test, indicating a phoric Other secondary causes may be aniseikonia,
component to the strabismus (Figure 7-7). These anisometropia, uncorrected vertical deviations,
microtropic patients usually show foveal suppres- and foveal lesions.
Chapter 7 231
46
Lang reported that most patients with microtro-
pia 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 strabis-
mic component. To measure this horizontal angle of
s&abismus objectively, the examiner must simulta-
neously 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 esti-
A
mated to be 5 . To measure this deviation, the doc-
tor must simultaneously occlude the left eye and
place the correct magnitude of base-out prism
before the right eye to neutralize any movement of
A
that eye (see Figure 7-8). If 5 base-out s placed
before the right eye and there s no movement of
A
that eye when the left s covered, then 5 is the mea-
sured magnitude. If there is eccentric fixation, that
must be taken into consideration to calclate the
fin/e strabismic deviation (see Chapter 4). In micro-
tropic 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 stri-
ated lens test. A transluminator light (or a penlight)
is the fixation target. The typical response of a FIGURE 7-8Unilateral neutralzation test. a. Preparing for the uni-
microtropic patient on this test is a report of the two lateral cover test for neutralization of an esotropic right eye with base-
out prism. b. Simultaneously covering the left eye with an occluder
lines crossing at the light but a small gap observed and the right eye with base-out prism. The prism power that equals the
in the line clued to the strabismic eye. The microtro- esotropic angle of the right eye neutralizes the angle of deviation so
pic angle of deviation can be directly observed by that eye movement does not occur.
free, with no cosmetic problem. In addition, they stereopsis in addition to elimination of the small
usually have rudimentary binocular visin with strabismus. These microtropes, however, were
fairly good fusional vergence ranges and peripheral known to have normal binocular development
(but not central) stereopsis. A small portion of prior to the onset of the microtropic deviation. 48
adult microtropic patients, however, do have
asthenopic symptoms related to the use of their
eyes. Like the heterophoric patient whose fusional CYCLOVERTICAL DEVIATIONS
vergence is nadequate for visual comfort and
Cyclovertical deviations involve either the oblique
efficiency, microtropic patients can have vergence
muscles or the vertical rectus muscles. Vertically
and accommoda-tive skills that are nadequate for
acting muscles have both vertical and cyclorotary
their visual needs at school, work, and play.
actions in most positions of gaze. Therefore, inner-
Prisms and added lenses do not seem to help n
vational or mechanical abnormalities of these
these symptomatic cases, possibly due to prism
muscles usually result in both a vertical deviation
adaptation. We have trained the visual skills of
and a cyclo deviation. Hyper deviations are also
many of these patients, often with good results.
prevalent among patients with horizontal strabis-
Vergence ranges ncreased to nearly normal
mus; nearly 40% of al I esotropes have a small ver-
levis, stereopsis ncreased slightly, and visual
tical component.49 Although vertical deviations are
symptoms disappeared after a relatively short
found frequently in combination with horizontal
office and home training program, from 6 to 10
strabismus, they can occur as isolated abnormali-
weeks in length. The microtropia still appeared on
ties. Because vertical fusional vergence s relatively
the unilateral cover test, but most patients were
weak as compared with fusional convergence or
pleased with the outcome. However, we have also
divergence, a small vertical deviation of even 1A or
seen some symptomatic microtropia patients for
2A may cause disturbing symptoms of diplopia,
whom no form of visin therapy relieved the
ntermittent blur, eyestrain, and nausea. Moreover,
symptoms. These patients had to avoid visual
a small vertical component can be the primary
activities that exacerbated their symptoms which,
obstacle to fusin in some cases of horizontal stra-
in some cases, required a change in employment.
bismus. Most cyclovertical deviations are noncom-
In most symptomatic microtropia cases, we
itant (see Chapters 8 and 15). In the next section,
recommend visin training similar to that
however, we discuss comitant vertical deviations.
provided in cases of heterophoria.
Some clinicians report having cured Comitant Vertical Deviations
microtropia n early childhood. von Noorden16 Isolated comitant vertical deviations greater than
discussed three patients younger than 5 years 10A are rare. On the other hand, small comitant
who had microtropia, anisometropia, and shallow hyper deviations, as isolated conditions or associ-
amblyopia. These patients wore spectacle lenses ated with modrate or large-angle horizontal devi-
for the anisometropia, and the dominant eye was ations, are common. Large angles of vertical
patched. The results ncluded elimination of the deviation (greater than 10A) almost always show
microtropia, 20/20 (6/6) visin in each eye, and signs of noncomitancy, including those with
stereoacuity of 40 seconds of are. It is possible paretic etiology and a subsequent "spread of comi-
that these patients were not actually microtropic tancy." Amblyopia and ARC are less often associ-
but instead had anisometropic amblyopia with ated with vertical deviations than with horizontal
eccentric fixation (which von Noorden noted) n strabismus. The etiology of comitant vertical devia-
which the movement on the unilateral cover test tions presumably includes anatomic factors and
reflected the eccentric fixation. Nevertheless, it abnormal innervation (Table 7-6).
seems prudent to treat any young patient with The obvious conservative treatment for a comi-
amblyopia, whether or not there is an associated tant vertical deviation, either heterophoria or stra-,
microtropia, with patching and optical correction bismus, is the prescription of vertical prism.:
when required. Apparent spontaneous remission Comitant vertical deviations of 10A or less can usu-i
of microtropia in young children may occur.47 ally be managed successfully with spectaclel
Early visin therapy in some primary micro- prisms if the prism amount s split between thej
tropes with associated amblyopia has been effec- eyes and the frame does not have a large vertical |
tive and resulted n normal visual acuity and dimensin. Vertical prism corrections greater tha
f233
may result n cosmetc problems due to the blastoma n infancy is, in fact, esotropa.50
optical displacement of the eyes. Vision training is
a second-choice treatment option to increase verti- TABLE 7-6. Characteristics of Comitant
cal fusional ranges. However, visin training often Vertical Deviations
is used n conjunction with prism therapy to help
to relieve symptoms. Mechanism tnnervational, anatomic
Cosmetic hypertropia or hypotropia greater Onset Birth to approximately 3 yrs
than 10A often requires surgical management. In Refraction Probably no relationship
patients with a combined horizontal and vertical Deviation Usually small angles, 1-104; often associated
strabismus, n which the vertical component is with modrate to large horizontal
less than 12A, surgical correction of the vertical strabismus, eso or exo deviation
deviation can often be accomplished by a vertical Can be intermittent or constant,
transposition (vertical offset) of the horizontal Constancy depending on magnitude and
muscles. To correct a hyper deviation, for exam- fusional status
ple, the insertions of the horizontal recti of the Comitant; may be secondary to a spread
higher eye are lowered. This procedure is done in Comitancy of comitancy after a non-comitant
addition to the appropriate recession or resection deviation
procedure for the horizontal deviation. To correct Often ARC if associated with a constant
for a hypotropia, the horizontal muscle insertions Correspondente horizontal deviation; ARC less prevalent
o the lower eye would be raised. Dale 3 reported than in pur horizontal deviations
that the correction ranges between 0.5A and 1.0A Amblyopia
Less than in horizontal strabismus
for each millimeter of offset surgery. For vertical More often than in horizontal strabismus
Symptoms
deviations of 12A or greater, it is usually necessary Poor if ARC; good if normal retinal
to recess the appropriate vertical muscles. For correspondente
Prognosis
example, if the patient has a comitant right hyper- ARC = anomalous retinal correspondente.
tropia of 25A, the superior rectus in the right eye
and the inferior rectus in the left eye should each Sensory strabismus s usually comtant but, if the
condtion is of long standing, secondary contrac-
be recessed to obtain the best possible comitant
tures can occur, restricting the horizontal move-
result.
ment of the affected eye. When a patient presents
with strabismus and reduced visual acuity in one
Dissociated Vertical Deviations eye, it is important clinically to establish which
DVDs, or so-called double hyper deviations, fre- condition preceded the other. Is the strabismus
quently are associated with infantile esotropa. secondary to the acuity loss, in which case a sen-
sory strabismus s present? Or s the acuity loss due
(See the discussion of DVD earlier in this chapter.)
to strabismic amblyopia, which has a good prog-
nosis for recovery if early patching and vigorous
visin training are initiated?
SENSORY STRABISMUS The direction of eye turn in sensory strabismus
A blind eye usually becomes a turned eye. When appears to relate to patient age at onset. In a series
sensory fusin is lost, strabismus usually results. of 121 sensory strabismus cases, Sidkaro and von
Severely reduced visual acuity in one or both eyes Noorden51 observed that esotropa and exotropia
can be an insurmountable obstacle to sensory were about equally distributed f the onset was
fusin. When the primary cause of a strabismus is within the first 5 years of life. However, if the sen-
loss of visin, then the term sensory strabismus is sory obstacle occurred later than age 5 years,
used to describe the condition. The causes of sen- exotropia predominated by a large margin. This is
sory strabismus are therefore as varied as the causes consistent with our clinical observations that f
of blindness or severe low visin. Some of the com- visin is lost in adulthood, an exotropia rather than
mon causes in early childhood include ocular esotropa usually occurs. It is not clear why some
trauma, congenital cataracts, optic atrophy or hypo-
plasia, congenital ptosis, and high anisometropia.
The second most common presenting sign of retino-
234 Chapter 7
patients become esotropic and others exotropic. for exotropia varies, according to different authors,
52 53 34
Chavasse speculated that there are various degrees from 6% to 20%. ' The mmediate recommenda-
of tonic convergence during early childhood, result- tion for small angles of consecutive esotropa is sim-
ing in either esotropa or exotropia, but during ply to wait and see whether the deviation resolves
adulthood there may be less forceful tonic conver- with the healing process. Many small overcorrec-
gence, in which case exotropia would predomnate. tions disappear with time, but larger deviations tend
In many cases of sensory strabismus, the very to increase. A large overcorrection with limitation of
nature of the condition precudes the restoration of ocular motility on the day after surgery may require
16
binocular visin (e.g., optic atrophy). In some cases further immediate surgical management. In most
of congenital cataract or ptosis, early surgery and cases of overcorrection, another operation should
proper optical correction may offer some hope of not be performed until after 6 months, unless there
recovering part or all of the visin loss. In most cases is a significant degree of noncomitancy. Attempts to
of sensory strabismus, however, therapy is directed elimnate diplopia can be made with compensating
toward improving the cosmetic aspects of the eye Fresnel prisms or spectacle overcorrection using
turn. If the deviation is relatively small, spectacle plus-fogging lenses over the deviating eye.
prisms may be used to correct the appearance of the The prevalence of consecutive exotropia is
strabismus (as described in Chapter 6). For larger lower than that of consecutive esotropa, ranging
deviations, cosmetic extraocular muscle surgery usu- from only 2% to 8%, depending on the investiga-
16
ally is advisable. The psychological consequences of tor. Consecutive exotropia can arise spontane-
a conspicuous, unsightly, turned eye are usually ously, although most are surgically induced. As a
worth preventing, particularly for school-aged chil- rule, consecutive exotropia decreases over time.
dren. The standard operation is recession and resec- Therefore, a wait-and-see policy is appropriate
tion of the appropriate horizontal eye muscles of the unless the deviation is extreme or complicated by
16
deviated eye. Surgical results in sensory strabismus a marked reduction of ocular motility. Six months
are often unpredictable, but adjustable sutures pro- is a reasonable waiting period. Attempts to align
vide a means of making postoperative corrections. the eyes and elimnate diplopia wth base-in
Long-term surgical results often are not as stable as in prsms or minus-lens overcorrection may prove
cases in which some form of binocular visin exists. beneficia!. In cases in which the AC/A ratio s mod-
The original deviation, or even a consecutive strabis- rate to high, we suggest prescrbing between 2
mus, can be the result over the years, requiring fur- and 4 D of minus-lens overcorrection for young
ther operations to maintain acceptable cosmesis.The patients as a temporary method for straghtening
patient or parents must be informed of this possibility. the eyes. In cases n which lens overcorrection is
indicated, we also recommend accommodative
facility training to prevent asthenopia.
CONSECUTIVE STRABISMUS
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17. Costenbader FD. Infantile esotropa. Trans Am Ophthal 39. Burlan HM. Pathophysiology of Exodeviations. In: Sym-
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18. Ingram RM, Barr A. Changes in refraction between the ed. St. Louls: Mosby; 1971:119.
ages of 1 and 31^ years. Br) Ophthalmol. 1979;63:339-
40. Wirtschafter JD, von Noorden GK. The effect of increas'mg
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lum'mance on exodeviations. nvest Ophthamol.
19. von Noorden GK. Infantile esotropa: a contlnuing riddle.
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Am OrthopJ. 1984;34:52-62.
41. Burlan HM, Smith DR. Comparative measurement of
exodeviations at twenty and one hundred feet. Trans Am
Ophthalmol Soc. 1971)69:188-192.
42. Scobee RG. The Oculorotary Muse/es, 2nd ed. St. Louis:
Mosby; 1952:172.
43. Pratt-Johnson JA, Tlllson G. Management of Strabismus
and Amblyopia: A Practical Cuide. New York: Thieme
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44. Biglan AW. Pattern Strabismus. In: C//n/ca/ Strabismus
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45. Breinin G. The physiopathology of the A and V patterns.
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46. Lang J. Lessons Learned from Mlcrotropia. In: Orthoptics,
Past, Present and Future. Moore S, Mein J, Stockbridge L,
eds. Miami: Symposia Specialists; 1976:183-190.
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Ophthalmologica. 1978;177:280-283.
236 Chapter 7
48. Cleary M, Houston CA, McFadzean RM, Dutton GN. 52. Chavasse FB. Worth's Squint or the Binocular Reflexes
Recovery n microtropia: implications for aetiology and and the Treatment of Strabismus, 7th ed. London:
neurophysiology. BrJ Ophthalmol. 1998;82:591. Ballere,Tindall, and Cox; 1931:519. Hardesty HH,
49. Scobee RG. Esotropa: incidence, etiology and results of 53. Boynton JR, Keenan JP. Treatment of inter-mittent
therapy. Am J Ophthalmol. 1951 ;34:817-833. exotropia. Arch Ophthalmol. 1978;96:268-274. Dunlap
50. Ellsworth RM. The practical management of retinoblas- 54. EA. Overcorrections n horizontal Strabismus sur-gery. In:
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erotropia. J Pediatr Ophthalmol Strabismus. 1982;19:12-19. Mosby; 1971:255.
Chapters / Other Oculomotor Disorders
Neurologa and muscular diseases affecting eff- three cranial nerves subserving ocular motility. In the
ciency of binocular visin are discussed in terms global sense, palsy refers to either a paresis or paraly-
of clinical diagnosis and management. A team sis. If the nerve damage s complete and no innerva-
approach often s required for proper manage- tion flows to the affected eye muscle, the strabismus
ment of these disorders. is said to be paralytic. If disruption of innervation is
partial, as is often the case, the term paretic is used.
Paresis can be of any degree, from mi Id to severe,
NEUROGENIC PALSIES depending on the extent of the muscle's dysfunction.
In cases of recent paresis or paralysis, the angle of
General Considerations deviation vares in magntude in different fields of
Noncomitant strabismus is considered neurogenic gaze. Also, the deviation vares depending on whch
palsy f it results from damage to one or more of the eye s fixating. The primary deviation refers to the
238 Chapter 8
TABLE 8-1. Etologic Frequency of Oculomotor Palsy TABLE 8-2. Differental Diagnosis of Paretic
Strabismus and Developmental Strabismus
In congenital or od cases of paretic strabismus, eyes, and a bilateral facial palsy (facial diplegia).
the clinician may find suppression, muscle con- Glasser,2 however, pointed out that the etiology is
tractures, and abnormal head posture. Od child- usually much more complex and little understood,
hood photographs may reveal a head-tilt pattern of because of the many other associated conditions.
long standing. In congenital cases, the pathologic Besides limited abduction and facial palsy, these
condition causingthe deviation is usually inactive; children are found to have variable disorders in sev-
however, if a patient reports a sudden onset of eral body systems, including an almost total lack of
diplopia, even when the deviation appears to be facial musculature; decreased bulk (atrophy) of one
comitant, it is advisable to suspect active pathol- side of the tongue; mild to modrate mental retarda-
ogy until proven otherwise. tion; congenital heart defects; limb and chest defor-
mities; hearing, speech, and swallowing difficulties;
and other manifestations.3
Sixth Cranial Nerve Ocular treatment usually involves correcting any
(Abducens) Palsy significant refractive error and providing visin ther-
The most prevalent noncomitant deviation is apy for amblyopia if present. These patients should
acquired sixth nerve paresis. Congenital sixth nerve be encouraged to adopt a crossed fixation pattern, if
palsy is rare, and determining the cause is often dif- they have not already done so, because abduction
fcult. Perinatal trauma is one possible etiology. The is limited. Surgical correction of the esotropa in the
i causes of acquired sixth nerve palsy are numerous. primary position might be attempted, but the results
feolder patients, the inciting event is often vascular are frequently unsatisfactory.
in nature (e.g., ischemic infarction). In patients
founger than 40 years, a frequent cause is mltiple
sderosis. When a vascular lesin is in the brain- Fourth Cranial Nerve
stem, the damage usually involves other nuclear (Trochlear) Palsy
centers as well, with obvious clinical manifesta- The fourth cranial nerves emerge dorsally from the
tions such as facial hemiplegia (damage to the fifth medullary velum and quickly decussate. This ana-
or seventh nucleus). Frequent causes are closed tomic relationship places these nerves in a vulnera-
head trauma or a blow to the side of the head, ble position from a blow to the forehead. Traumatic
rhere the sixth nerve is particularly vulnerable. closed head injury from a frontal blow is one of the
If a sixth nerve palsy occurs during visual imma- main causes of superior oblique palsy, unilateral or
urity, suppression, amblyopia, or even anomalous bilateral. Even minor head injuries can result in
etinal correspondence can develop. In older nerve damage. The causes of fourth nerve palsies
patients, diplopia is usually reported. The deviation are numerous. Frequently, the etiology is vascular.
and diplopia increase in the field of gaze of the The nutrient vessels to the nerve, the vasa nervorum,
involved lateral rectus muscle. A compensatory can be occluded, causing an ischemic infarction
head turn is made in the direction of the action field and the death of the nerve. Damage can also occur
o the affected eye. If the paresis is severe, the duc- when blood leaks from vessels as a result of diabe-
tion (monocular) may be limited in the involved tes. In cases of unexplained nerve involvement, a
field of gaze and, generally, an abnormal versin glucose tolerance test is appropriate. Herpes zoster
frinocular) movement is even more noticeable is another potential etiologic factor.
Ibecause of increasing magnitude of the deviation) The most prominent sign of a recent superior
tfian is the abnormal monocular duction. Manage- oblique palsy is a hypertropia in the primary posi-
ment of noncomitancy is discussed in Chapter 15. tion that increases in down-gaze and with conver-
gence. Also in primary position, there is an excyclo
deviation and often a small eso deviation. In the
Mbius (Moebius) Syndrome case of weakness of the left superior oblique mus-
One special condition involving bilateral sixth cle, for example, the compensatory head turn
nerve palsy is Mbius syndrome. This congenital would be a right head tilt, a right head turn, and
condition was once believed to be caused by a chin depression. (See the discussion of abnormal
bilateral palsy of the abducens (sixth) and facial head posture in Chapter 4.) A positive Bielschowsky
Iseventh) nerves, because patients were found to head-tilt test (left hypertropia increases on left head
have an esotropa, a bilateral inability to abduct the tilt) is an indication that the underlying disorder is
240 Chapter 8
New axons that are misdirected innervate inappro- floor). In the primary position, a hypertropia of the
priate muscles, resulting in the paradoxical ocular affected eye is found. An incyclo deviation of the
movements and pupillary reactions characteristic involved eye is expected. If there is no restriction
othis syndrome. of the superior rectus as revealed by the forced
Acquired third nerve palsy is a fairly common duction test, a small hypertropia can usually be
neurologa condition. Depending on the site of the corrected surgically by resection of the affected
lesin, the entire nerve can be affected (resulting inferior rectus. However, if a superior rectus
in the characteristic signs described earlier for restriction is found, it must be recessed as well. In
congenital third nerve palsy), or only a particular large deviations, a combined recession of the
divisin or isolated root of the nerve can be dam- superior rectus and a resection of the inferior rec-
aged. Isolated palsies of various extraocular mus- tus can correct up to 40 A of vertical deviation in
cles supplied by the third cranial nerve occur less the primary position.
commonly than a more generalized condition. An isolated inferior oblique palsy is also extremely
Any degree of paresis can be present. Deficiencies rare and can be either congenital or acquired. A
in elevation, depression, and adduction, along hypotropia and incyclotropia are seen if the patient
with ptosis, occur in various combinations with or fixates with the nonparetic eye. The vertical deviation
without pupillary involvement. When there is in the primary position, however, generally is not as
extraocular muscle weakness along with pupillary large as in cases of isolated superior rectus or supe-
involvement, the condition is called infernal oph- rior oblique palsy. If the patient chooses to fixate with
tialmoplegia. However, externa] ophthalmoplegia the paretic eye (as in some acquired conditions in
K indicated when extraocular muscle weakness which the paretic eye has been the dominant sighting
exists without pupillary involvement. eye), a hypertropia of the noninvolved eye is found.
Isolated superior rectus palsy is usually congeni- As the patient moves the paretic eye into adduction,
tal. When the uninvolved eye fixates in the primary the contralateral hypertropia increases greatly. This
position, a hypotropia of the affected eye s seen. The observation is called the rising eye syndrome (more
hypotropic deviation increases maximally when the correctly, rising eye s/gn). A recommended surgical
patient moves the affected eye into the field of action procedure for an isolated inferior oblique palsy is to
o the superior rectus muscle, the superior temporal recess the contralateral superior rectus and resect the
field. Because most such palsies are congenital, the contralateral inferior rectus muscle. This procedure
patients do not usually report any symptoms. The gives greater comitancy when the paretic eye s
recommended surgical procedure for an isolated adducted.
superior rectus palsy consists of an appropriate Double elevator palsy can be either congenital
amount of inferior rectus recession and superior rec- or acquired. All patients described as having dou-
tus resection in the involved eye. A 4-mm recession ble elevator palsy must demnstrate an inability to
of the inferior rectus, by itself, may give up to 15A of elvate the affected eye from any horizontal posi-
vertical correction in the primary position.7 A reces- tionprimary, adduction, or abduction. Some
skwi-resection operation of the same amount may patients present with a chin elevation, indicating
provide as much as 40A of vertical correction. that they can fuse in down-gaze. Visual acuity is
Isolated medial rectus, inferior rectus, and infe- usually good in each eye. Patients often report
rior oblique muscle palsies are extremely rare. diplopia with fixation in the primary position.
These three muscles all are innervated by the infe- Other congenital cases show a hypotropia of the
rior divisin of the third nerve, so damage to that affected eye, a pseudoptosis due to the hypotropia,
root tends to involve all three muscles. However, and deep amblyopia.
isolated palsies do occur occasionally for inexpli- At one time, double elevator palsy was believed
cable reasons. In solated medial rectus palsy, a to be caused by weakness of both the superior rec-
noncomitant exotropia is seen along with limited tus and inferior oblique muscles of the affected
adduction. The corrective surgical procedure is eye, but the anatomy of the third nerve casts doubt
usually recession-resection of the horizontal mus- on this explanation. Within the third nerve nucleus
cles in the affected eye. The extremely rare isolated complex, innervation for these two muscles arises
inferior rectus palsy can be congenital or acquired. from disparate locations. Because the superior rec-
When it is acquired, the cause s usually head tus is nnervated by the superior divisin of the
trauma (e.g., a blowout fracture to the orbital nerve and the inferior oblique by the inferior divi-
242 Chapter 8
Sons of the disease often are managed on a syrnp- orly (.e., Dalrymple's sign). Eyelid retraction associ-
omatic basis. ated 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
Dysthyroid Eye Disease series of 200 cases. In proptosis of nonthyroid origin,
The association of hyperthyroidism and eye disease patients usually do not have eyelid retraction,
has been known for two centuries. In 1835, although exceptions do occur. Because of the eyelid
Graves13 described the eye signs of a hyperthyroid retraction, the patient may have the appearance of
tmale patient n detail, particularly exophthalmos staring or being startled. Infrequent and ncomplete
Iproptosis). Henee, Graves' ame became attached blinking often occurs. On down-gaze, the upper eye-
to the condition when exophthalmos is present. lids usually lag, exposing sclera superiorly (.e., von
Graves' ophthalmopathy can appear at any time Graefe's sign). Exophthalmos is not always pathogno-
during the course of hyperthyroidism with its ele- monic of thyroid eye disease. Many other conditions
wated levis of thyroid hormone. Systemic symp- (e.g., high myopia, steroid use, Cushing's syndrome)
toms include nervousness, irritability, emotional result in proptosis or a pseudoproptosis. However,
bbility, sweating, palpitations, difficulty breathing, the combination of bilateral exophthalmos, eyelid
fatigue, weight loss, increased appetite, leg swell- retraction, stare, and an enlarged thyroid are virtually
ng, and ncreased bowel movements. Commonly pathognomonic of Graves' disease.14
associated signs are goiter (enlarged thyroid), tachy- Proptosis in Graves' disease is caused by extraoc-
cardia, skin changes with abnormal pigmentation, ular muscle enlargement. The muscles are usually
and tremor.14 Thyroid eye disease in children and enlarged two to five times their normal size due to
adolescents is uncommon; the condition occurs fatty infiltrates, lymphocytes, macrophages, mast
most commonly in women 30-50 years od, and cells, and interstitial edema.19'20The increased muscle
Ihe prevalence peaks again in 60-year-olds. The size s not due to the muscle fibers themselves,
overall female-male ratio for systemic hyperthyroid- which histologically appear normal, but to inflam-
ism is 4 to 1 but, n thyroid eye disease, the ratio s matory infltrales, cells, and edema. Orbital connec-
lower, approximately 2.5 to 1.O.15 At the time of tive tissue and extraocular muscle antibodies have
diagnosis, the eye symptoms and signs associated been detected in the serum of patients with Graves'
with hyperthyroidism occur in 20^0% of patients. ophthalmopathy.21 The immunologic mechanism of
Most patients present with the systemic symptoms. involvement is not well understood. Because of the
However, approximately 20% nitially seek ophthal- enlarged muscles, there s a resistance to retropul-
mologic or optometric care due to the ocular mani- sion (pressing the eye back into the orbit). The most
festations, without prior identification of systemic commonly involved extraocular muscles in thyroid
hyperthyroidism.16 Graves' disease is an autoim- eye disease, in order of frequency, are the inferior
mune disorder, although its etiology and pathology recti (80% of patients), medial recti (44%), superior
are not precisely understood. The goal of laboratory recti, and lateral recti.22 Oblique muscles rarely are
studies is to demnstrate either systemic hyperthy- involved.
roidism or altered immune response to thyroid- Inferior rectus nvolvement results in a tethering
related antigens, or both. Char14 recommended the of the eye, restricting movement n up-gaze. In this
diagnostic laboratory test for thyrotoxicosisdeter- case, the forced duction test s positive for a restric-
mination of the serum thyroid-stimulating hormone tive myopathy of elevation. Patients often report
level, which s abnormally low in this disease. diplopia in up-gaze and, eventually, n the primary
Proptosis of the eyes s a common sign associated position; in fact, the most common cause of spon-
with Graves' ophthalmopathy. Bilateral exophthal- taneous diplopia n middle-aged or older patients
mometer readings n excess of 22 mm or a difference is Graves' disease.14
between the eyes of 2 mm or more is regarded by Increased intraocular pressure (IOP) can occur
most clinicians as suspicious of orbital pathology. The due to the pressure of the muscle against the eye on
average amount of proptosis in Graves' disease is not attempted up-gaze. Some i nvestigators believe that
large (approximately 3 mm) as compared to con- a 4-mm ncrease in IOP between inferior and supe-
trols.17 There is usually some proptosis asymmetry. rior gaze is highly suggestive of restrictive myopathy.
The eyelids usually are retracted in cases of Graves' Gamblin et al.23 observed that al I patients with
disease, and the sclera shows superiorly and inferi- long-standing thyroid exophthalmos had increased
244 Chapter 8
onally, other facial muscles, especially those used 3. Retraction of the globe on adduction with
in mastication.29 Chronic progressive external oph- narrowing of the eyelids
almoplegia s also known as ocular myopathy of 4. Esotropa of the affected eye in the primary
non Craefe. The first presenting sign s often bilateral position, frequently greater at far than at
sis that does not improve with the administration near. Exotropia and nonstrabismus are less
ranticholinesterase agents, unlike the ptosis found i often seen
myasthenia gravis. There s usually a slowly pro- 5. Often, the necessity for a head turn in the
pessive loss of ocular motility affecting elevation direction of the affected eye to achieve lim-
ore than other fields of gaze. In extreme cases, ited range of binocular fusin
y is lost in all fields of gaze and the eyes 6. Poor gross convergence (remote nearpoint
fappear frozen in place. The onset is usually before of convergence)
i 30 years of age and may occur during early child-
There are several etiologic factors that com-
fcood. The condition appears to be genetic in origin,
bine to account for the features of the retraction
laecting men and women equally.
Treatment s based on the patient's symptoms. A i syndrome. Electromyographic studies indcate a
misdrected innervational pattern. On attempted
ptosis crutch may be required to relieve the droop-
abducton, the lateral rectus muscle is often elc-
ing eyelids. Prism therapy and surgical alignment
trica! ly silent. In some cases, the sixth nerve and
othe eyes may be necessary to elimnate diplopia
nucleus are absent.33 In addition, t was found that
isome patients, often with satisfactory results.
several small branches of the inferior divisin of
the third nerve enter the lateral rectus. Wth adduc-
tion, nnervation flows to both the medial and the
MECHANICAL RESTRICTIONS lateral rectus simultaneously, although the medial
OF OCULAR MOVEMENT rectus receives the greater proportion. This anoma-
Noncomitancy may be caused by restriction of lous innervation pattern causes co-contraction of
traocular muscles. Several causes are discussed both horizontal muscles. Co-contraction results in
in this section. retraction of the globe, partial limitation of adduc-
tion, and narrowing of the palpebral fissure. Evi-
dence that Duane retraction syndrome is a
Duane Retraction Syndrome mechanical restriction s supplied by the result of
Ahhough Duane was not the first to identify this the forced duction test. All cases show some physi-
etraction syndrome, n 1905 he rigorously ana- cal limitation to passive movement of the globe,
lyzed a series of 54 cases and his ame, subse- and most show marked limitation. Fibrosis of the
quently, became attached to the condition. The lateral rectus muscle has been confirmed by
syndrome s a fairly common congenital anomaly biopsy in many cases. It is possible, however, that
Ihat has been reported in infants as young as 1 day the mechanical restriction s secondary to the
dd.30It has been found in monozygotic twins, anomalous innervation pattern.
indicating a genetic basis.31 There appears to be an Significan! variations from the classic form of
autosomal dominant pattern, but many cases are Duane retraction syndrome have been reported by
sporadic. The retraction syndrome has an unex- many authors. Huber34 suggested the following
plained predilection for the left eye (3 to 1) and classification, which describes three principal
seems to occur more often n females, although types (Figure 8-2):
some evidence casts doubt on this last observa-
tion.32 Approximately 20% of cases are bilateral. 1. Duane I: Marked reduction or absence of
The clinical characteristics in its classic form are abduction, mildly defective adduction,
as follows: retraction on adduction with eyelid nar
rowing. This s the classic and most preva-
1. A marked limitation or absence of abduc- lent form.
tion, often associated with widening of the 2. Duane II: Marked reduction or absence of
eyelids on attempted abduction adduction, mildly defective abduction,
2. A mild to modrate limitation of adduction, retraction on abduction with eyelid nar
often associated with an up-shoot or down- rowing. This is sometimes called the inversa
shoot of the eye on adduction Duane.
246 Chapter 8
3. Duane III: Marked limitation of both abduo tion may be some limitation of elevation in the primary
and adduction, retraction of the globe with position and even on abduction n some cases. The
narrowing of the eyelids on adduction. This is the condition usually affects only one eye, although
rarest form of the three. we have seen several bilateral cases. Many patients
maintain normal binocular visin in the primary
The majority of patients with Duane retraction
position, but many have hypotropia, esotropa, or
syndrome are asymptomatic. Many have a
exotropia of the affected eye. Brown syndrome s a
restricted range of binocular fusin and learn to
congenital anomaly with familial occurrence. Mr-
turn the head habitually (rather than the eyes) to
ror reversal (i.e., opposite eye affected) has been
fixate. When strabismus is present, suppression is
reported n monozygotic twins.36
usually deep, preventing diplopia or other visual
The clinical characteristics of Brown syndrome
symptoms. In those few cases that do present with
are as follows:
symptoms related to fusional control of the devia-
tion, visin therapy can be attempted to build 1. Absence or marked limitation of elevation
fusional reserves. (See Chapter 15 for a description on adduction
of such a case.) Surgical intervention s usually 2. Normal or near-normal elevation in the pri
considered only to reduce a cosmetically disfigur- mary position and on abduction
ing strabismus or head turn and not necessarily to 3. Possibly, depression of the affected eye
increase ocular motility or fusin ranges. When (hypotropia) on versions (nasalward posi
surgery s indicated, simple procedures generally tion of the eye)
are recommended, mainly medial or lateral rectus 4. Usually, widening of palpebral fissure on
recessions. adduction
5. Divergence in up-gaze, usually a V pattern,
Brown (Superior Oblique with or without a strabismus in the primary
position
Tendn Sheath) Syndrome
6. Restriction to elevation on adduction with
The predominant feature of Brown syndrome s the forced duction test (see Chapter 4 for
reduced or absent elevation on adduction.35 The
discussion of forced duction testing)
same degree of restriction is present on versions
(binocular) and ductions (monocular). There also Several etiologies have been found n Brown
syndrome.35 The superior oblique tendn sheath
Chapter 8 247
sheath s short and s fixed at the pul ley and the tal is suspensions to correct the ptosis. There is a
tendn nsertion, t becomes a physical barrier to danger of causing exposure keratitis, which, if t
adduction of the eye. On adduction, the globe occurs, would require further surgical intervention.
slips under the stretched sheath and, in some Strabismus fixus s a rare congenital condition in
cases, there s an audible "click." The sheath pre- which one or both eyes are tethered in an extrem e
*ents elevation on adduction. Other cases have position of gaze, usual ly convergent and exceed-
A
been reported in which the tendn itself fails to ing 100 . In most cases, this anomaly is cosmeti-
slip through the pul ley and restricts ocular motility cally less acceptable than the generalized fibrosis
in the same manner as just described. syndrome. The eyes are firmly fixed n position,
Some individuis with Brown syndrome have which is easily confirmed by the forced duction
perienced spontaneous recoveries. There is a test. The patient must assume an extreme head turn
sudden relase of the restriction, the tendn moves to fixate with the preferred eye, as one eye is cho-
normally through the pulley, and full motility s sen over the other by habit. This anomaly is con-
ealized. It s interesting to note that more cases of genital and is believed to be due to fibrosis of the
Brown syndrome are found in children, suggesting medial rectus muscles. The condition is treated
tfiat many cases do resolve spontaneously. surgically, preferably at an early age, by an exten-
Other, less prevalent etiologies include an anom- sive recession of the medial recti and the overlying
aly of the superior oblique muscle, paradoxical conjunctiva. The eyes are anchored in a slightly
mervation analogous to the findings n Duane abducted position, and mximum resection of the
retraction syndrome, surgically induced restrictions, lateral recti may help to hold the eyes in a central
and restriction secondary to paralysis of the inferior position. Even though postoperative ocular motility
37
oblique muscle. will be very limited, cosmetic and functional
Many patients with Brown syndrome have nor- improvement may be considerable.
mal binocular visin n the primary position, expe-
nence no visual symptoms, and have learned to Adherence Syndromes
move the head rather than the eyes to the affected 38
Johnson described two very rare restriction anoma-
field of gaze. Surgery s not recommended unless
lies called adherence syndromes. These are usual ly
diere is a significant strabismus, usually hypotro-
acquired, often introduced by previous eye surgery;
pa, in the primary position or the patient has
however, a few congenital cases have been reported.
adopted a cosmetically unacceptable head turn.
35 In the lateral adherence syndrome, the muscle
Brown advocated dissecting and stripping the
sheaths of the lateral rectus and the inferior oblique
sheath while leaving the tendn intact. Although
muscles are joined by abnormal fascial tissue attach-
hb cure rate was only 20%, some improvement
35 37 ments. This unin produces a limitation of move-
was reported in 50% of the cases. von Noorden
ment n the field of action of the lateral rectus (i.e.,
recommended performing a complete tenectomy
abduction). The forced duction test reveis a lateral
o the superior oblique muscle, which dramatically
restriction to passive rotation of the eye.
improves the restriction. This, however, creates a
In the superior adherence syndrome, there s
weakness in inferonasal ductions, and further sur-
abnormal adherence between the superior rectus
gery often is required. Patients should be carefully
muscle sheath and the superior oblique tendn that
sdected for surgical treatment of Brown syndrome.
produces a limitation of movement n the field of
action of the superior rectus. Diagnosis is often estab-
fibrosis of the lished during surgery using the forced duction test.
Extraocular Muscles Treatment for these adherence syndromes requires
loosening the adhesions by forcefully rotating the
Generalizad fibrosis syndrome s usual ly an auto-
globe after detaching the lateral or superior rectus
somal dominant anomaly n which all the extraoc-
muscle.
ular muscles, including the levator, are fibrotic.
Both eyes are tethered downward, and the patient
devates the chin to fixate. A bilateral ptosis s usu- Orbital Anomalies
ally evident. Surgical treatment s often unsatisfac- A blowout fracture of the orbit may occur as a result
tory. One surgical approach s to recess both of blunt trauma to the soft tissues of the eye, as
inferior rectus muscles and perform bilateral fron- when an eye is hit with a tennis ball or a fist or the
248 Chapter 8
, associated with little or no adduction of either basilar artery and often is accompanied by vr-
eye (Figure 8-3). INO can be distinguished from an tigo and other brainstem symptoms.41 Other rare
solated medial rectus palsy, which also results in a causes of INO have been reported; these nclude
loss of adduction, by the associated abduction nys- brainstem and fourth ventricular tumors, hydro-
lagmus on lateral gaze. cephalus, infections (including those associated
The saccadic, pursuit, and vestbulo-ocular sys- with the acquired mmunodeficiency syndrome),
tEms al I are affected; however, gross convergence pernicious anemia, head trauma, and drug intox-
K usually intact. This presentation s seen in the ications (e.g., narcotics, tricyclic antidepressants,
most prevalent type, Cogan's posterior INO, due to lithium, barbiturates, and other psychoactive
a pontine-level lesin of the MLF.41 A unique fea- drugs).42
ture in pontine INO s that the medial rectus mus- Treatment options for INO are limited. Ocular
de contracts in response to a convergence manifestations are managed on a symptomatic
stimulus but does not contract in response to a ver- basis. Patients usually do not present with a stra-
sin stimulus. INO produced by a midbrain lesin, bismus n the primary position and therefore do
however, is usually bilateral with a reduction or not report diplopia except on lateral gaze. They
afcsence of gross convergence (Cogan's anterior compnsate by turning the head rather than the
INO).41 eyes for lateral fixation. Comfortable reading and
There is often a coarse vertical nystagmus on up- safe driving, however, may require patching an
gaze of both eyes in unilateral and bilateral cases. eyeeither total or partial occlusion. There may
Most patients with INO have no strabsmus in the be some spontaneous or slow recovery of func-
primary position, unlke n medial rectus paresis. tion with healing f the cause is of vascular origin.
Occasionally, a horizontal strabismus s found Patients with mltiple scierosis frequently experi-
superimposed on an INO, due to specifc involve- ence periods of remission and recovery of some
ment of the respective nuclei (.e., an exotropia motor functions during the course of the disease.
associated with a lesin of the medial rectus com- However, no treatment for mltiple sclerosis is
ponentof the oculomotor nucleus [cranial nerve III] yet available that has proven effective in the long
or an esotropa due to abducens nucleus [cranial term.
nerve VI] or nerve damage).
There are two prmary etiologies of INO. Bilat-
eral INO in a young adult s most often caused Supranuclear Horizontal
by mltiple sclerosis, a demyelnating disease, Gaze Palsy
whereas INO in patients older than 50 years is Frontal Eye-Feld Lesions
frequently caused by a vascular lesin (e.g., an The two most common causes of lesions n the fron-
intarction). When mltiple sclerosis s the cause, tal cortex (Brodmann's rea 8) are acute cerebrovas-
there are often other presenting symptoms such cular accident (stroke) and head trauma. The frontal
as decreased bladder control, limb weakness, eye fields initiate voluntary saccadic eye movements,
unusual paresthetic sensations, or optic neuritis. so a lesin on one side results in a conjgate turning
Unilateral presentation almost always indcales of the eyes (and, usually, the head) toward the side of
an nfarct (occlusion) of a small branch of the the lesin; the contralateral rea 8 has unopposed
250 Chapter 8
action. If the lesin s isolated and the patient is suffi- the PPRF is the beginning of the final common
ciently conscious, pursuit eye movements can be pathway to the horizontal oculomotor nuclei. Con-
demonstrated on either side. Because the vestibular sequently, if a patient presents with a complete
pathway s intact, the eyes can move into the field unilateral gaze palsy for all eye movements, the
opposite the lesin by applcatin of the doll's-head most likely cause is a lesin in the pons involving
maneuver. Eventually, this gaze palsy may partially the lateral gaze center.
resolve, possibly as a result of other systems (e.g.; the
43
superior colliculus) generating saccades.
Supranuclear Vertical Gaze Palsy
Occipital and Parietal Cortical Lesions Isolated lesions producing vertical gaze palsy are
An extensive lesin n the parieto-occipital lobe sec- rare. Bilateral up-gaze dficits have been reported in
ondary to a vascular accident or tumor s the most the literature more often than have down-gaze pal-
likely cause of a gaze-dependent disorder of pursuit sies. The reported cases usually involve vascular
eye movements. The patient s unable to follow a lesions or metastases in portions of the MLF con-
moving target smoothly but uses a series of small sac- necting the fourth and third nerve complex or in
12
cadic steps for tracking. These saccadic steps are connections with the superior colliculus. Most
known as cogwheel pursuits. To a lesser degree, cases of vertical gaze palsy involve generalized neu-
smooth pursuit tracking is reduced with age in many rologic syndromes of which the gaze palsy s merely
people, but the loss is usually symmetric in direction. one, although possibly the first, of many expressions
The smooth pursuit phase of optokinetic nystagmus of the disease process.
(OKN) s similarly affected when the stripes are
rotated n the direction of the lesin, but t should be Parinaud Syndrome
normal when the stripe rotation is reversed (i.e., Often the first sign of Parinaud syndrome s up-gaze
toward the opposite side of the lesin). The associ- saccadic dysfunction. Initially, the patient finds that
ated and definitive clinical sign of this pathologic making up-gaze eye movements requires much
condition s homonymous hemianopsia. effort; the eyes may swing back and forth in a serpen-
Lesions located solely n the occipital regin tine movement when elevation s attempted. With
result in a visual field cut, often without pursuit elevation effort, the eyes often converge while simul-
abnormalities. Lesions n the parietal regin, how- taneously retracting into the orbits. Many patients
ever, often produce visual agnosia, so that interpre- later have convergence-retraction nystagmus with
tation of a visual image's meaning is defective (i.e., oscillopsia. The nystagmoid movements can be exag-
apperceptive agnosia). gerated by rotating OKN stripes downward, thus
Patients having parieto-occipital lesions initially requiring upward saccades. Convergence-retraction
require management by a neuro-ophthalmologist, nystagmus on vertical OKN testing is a common sign
but they usually can be followed subsequently by in Parinaud's syndrome. Other common signs
the primary eye care doctor. include dilated pupils that are unresponsive to light,
anisocoria, light-near dissociation (i.e., pupil con-
Brainstem Lesions striction to a near stimulus but not to light), and
Brainstem lesions affect the descending fibers in papilledema (Table 8-7). The sluggish pupillary light
the brainstem, from the cortical reas subserving response and nystagmus are indicators that the up-
pursuit and saccadic eye movements to the lateral gaze restriction s not orbital in nature, as t s in
gaze centers n the pons, specifically, the parame- Graves' disease. High-resolution CT scanning and
dial pontine reticular formation (PPRF). Stroke s magnetic resonance imaging are generally helpful in
the most likely cause of lesions n the rostral brain- the differential diagnosis. Parinaud's syndrome usu-
stem, whereas lesions at a lower level in the pons, ally indicates a neuro-ophthalmologic emergency.
involving the PPRF, can arise from several sources Parinaud syndrome can be congenital or
(e.g., vascular origin, demyelinating disease, and acquired. Its other ames, sylvian aqueduct syn-
43
tumors). If these descending fibers are inter- drome and dorsal midbrain syndrome, indcate its
rupted, both pursuits and saccades are deficient or etiology. This syndrome frequently s caused by
absent on the side of the "deprived" lateral gaze sylvian aqueductal stenosis (i.e., a restriction of
center. If a lateral gaze center itself s damaged, cerebrospinal fluid that flows between the third and
vestbulo-ocular responses can also be affected, as fourth ventricles), resulting in hydrocephalus and
Chapter 8 251
TABLE 8-7. Occular Signs of Parinaud Syndrome TABLE 8-8. Ocular Signs of Parkinson's Disease
(Dorsal Midbrain Syndrome)
45
ders. Approximately 10-15% of visually impaired
TABLE 8-9. Clinically Relevant Characteristics of school-aged children have nystagmus. Nystagmus
Nystagmus can be conceptualized as a disorder of the mecha-
42
nisms that maintain stable fixation.
Characterlstic Nystagmus, affecting approximately 0.4% of the
Observations 46
general population, is not a disease entity as such;
Global observations General posture, head position rather, it is a sign of an underlying disorder. The clini-
(turns or tilts), facial asym- cian should attempt to describe the condition as
roetries either congenital or acquired and determine the gen-
Type of Pendular, jerk, or mixed eral category of etiology (e.g., genetic, traumatic,
nystagmus Horizontal, vertical, torsional, or toxic, metabolic error, developmental, visual depriva-
Direction combination tion). This discussion will focus on the most prevalent
Small {>2 degrees), modrate (2- types of nystagmus: physiologic, voluntary, congeni-
Amplitude 10 degrees), large (>10 degrees) tal, and latent. Rarer types, which may be harbingers
Slow (V2 Hz), modrate (\-2 Hz), fast (>2 of active neurologic disease, are presented later in
Frequency Hz)
Table 8-16 for the purpose of differential diagnosis.
Constantly present, intermit-tent, Many clinical tests in the routine visin examina-
Constancy periodic
tion are complicated by the presence of nystagmus.
Conjgate (eyes move in same direction); The patient's inability to maintain steady fixation
Conjugacy disjunctive (eyes move independently)
affects the accuracy of keratometry, retinoscopy, sub-
Symmetry (oculus Symmetric (equal amplitudes); jective refraction, the cover test, internal and externa!
dexter and ocu- asymmetric (unequal amplitudes) health inspection, and other measurements. For this
lus sinister) Increase of nystagmus with occlusion reason, the clinician must exercise skill, patience,
Latent component of one eye and persistence in clinical evaluation. The gross
Nuil point, dampening, or increase
observation of nystagmus is necessary in all fields of
Field-of-gaze of nystagmus in any field of gaze or
gaze and at far and near distances, as many types of
changes with conver-gence
nystagmus show significant variation n these
respects. Magnificaron (e.g., loop, binocular ndirect
ophthalmoscope, or slit lamp) is often useful for
often unpredictable periods of observing the characteristics of nystagmus. Table 8-9
remission during which systemic and ocular signs presents characteristics of nystagmus that are clini-
diminish but, overall, the condition is progressive. cally relevantfor differential diagnosis.
Patients often are directed toward psychological
support groups to help them adjust emotionally to
the limitations of their condition. Physiologic Nystagmus
In a person who is very tired, it is not unusual for a
jerk nystagmus to develop in extreme positions of
NYSTAGMUS gaze (Table 8-10). This s a normal type of nystag-
mus and of no particular consequence; it disappears
The appearance of nystagmus in early childhood or
after a good sleep. The oscillations are of small
later in life causes considerable distress for patients,
amplitude, conjgate, and rapid, and may be
family, and friends. Its presence usually is interpretad
unequal in each eye. It is present only at the
as a sign of serious visual dysfunction or, possibly,
extremes of horizontal and, occasionally, vertical
brain damage. Nystagmus (i.e., the involuntary rhyth-
gaze. Because the condition is related to fatigue, t
mic oscillations of one or both eyes) may indeed be
is usually ntermittent but, if sustained, it must be
the presenting sign of either a pathologic afferent
distinguished from pathologic types of nystagmus. A
visual pathway lesin or a disorder n oculomotor
reasonable clinical guideline is to regard as physio-
control. Thirteen percent of cerebral palsy patients
logic the fine conjgate jerk nystagmus detected
have nystagmus, among many other visual disor-
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 8 253
quently as women.51 It is notoriously variable but, even though the eye may be in constant motion,
fortunately for the sake of differential diagnosis, but one may find head nodding or shaking.
certain clinical features are highly characteristic The specific neuropathology resulting in congen-
and distinguish it from other forms of nystagmus ital nystagmus is not well understood in most cases,
(Table 8-12). It is present at birth or shortly thereaf- but the clinical conditions that cause it can be
ter and, for this reason, is sometimes referred to as broadly classified as afferent and efferent. Afferent
nfantile nystagmus. The oscillations can be solely congenital nystagmus is associated with poor visual
jerk (the most prevalent pattern), solely pendular, acuity. Congenital optic nerve atrophy or hypopla-
or a combination of the two. The oscillations can sia, congenital cataracts, ocular albinism, achro-
convert from one waveform to another spontane- matopsia, and aniridia are all diseases of the eye or
ously or may do so in different fields of gaze. If the the afferent visual pathway that can result in con-
waveform pattern is jerk, then the fast phase most genital nystagmus. Visual acuity reduction usually is
often occurs in the direction of gaze.52 Amplitude profound, and the prognosis for improvement poor.
and frequency can vary from moment to moment In these patients, who represent approximately 40%
and, on occasion, the eyes may become "quiet." of all congenital nystagmus cases, the etiology is
The amplitude usually increases in some field of usually obvious on clinical examination.
gaze and, for this reason, a patient may habitually The majority of congenital nystagmus cases,
assume a head turn or tilt to dampen the nystag- approximately 60%, are considered to be efferent,
mus as much as possible. The position of gaze in due to some disorder of the oculomotor systems. A
which the eyes are quiet is known as the nuil disorder or lesin of the pursuit system at the level
regin. The nystagmus often is accentuated by of the brainstem is suspected by some authori-
active fixation, attention, or anxiety and may be ties.42 Lo54 reported CT sean abnormalities in 50% of
diminished by convergence and purposeful eyelid congenital nystagmus patients. Magnetic reso-
closure.53 It usually presents as conjgate and hor- nance imaging scanning may identify an even
izontal, but occasionally clinicians see vertical and higher percentage in the future. There is often a
torsional waveforms or some combination of these. hereditary pattern of involvement, but some family
When the nystagmus is horizontal, it usually members may have one waveform (e.g., jerk) and
remains horizontal even on up- and down-gaze. some another (e.g., pendular). In most efferent
The condition rarely is associated with oscillopsia, cases, the etiology is idiopathic. Patients with effer-
Chapter 8 255
ent congenital nystagmus usually have better forms. There s usually a latent component. A family
visual acuity than do those with afferent types. history may reveal a genetic condition. Spasmus
The prevalence of strabismus in congenital nys- nutans is an altogether different type of nystagmus
tagmus is high, 40-50%.5S The eye turn s usually and has a later onset than congenital nystagmus. It
esotropic; however, exotropias and hypertropias s characterized by high-frequency, small-amplitude
frequently are found. Identifying the strabismus oscillations that often are intermittent and asymmet-
may be difficult due to the pattern of nystagmoid ric when comparing each eye (Table 8-13). For fur-
movements, so it is possible that the prevalence of ther information on differential diagnosis, the reader
strabismus in these cases is actually underesti- is referred to an extensive review by Grisham.56
mated. The etiology of a strabismus can be com-
pletely independent of that causing the nystagmus,
but most often the two conditions appear to be Nystagmus Blockage Syndrome
part of the underlying problem affecting the visual A less well-known form of congenital jerk nystag-
system. One controversial view is that most cases mus is associated with esotropa. The amplitude of
of esotropa associated with congenital nystagmus nystagmus is reduced or absent with convergence
are secondary to the nystagmus and orignate as an when the fixating eye s adducted. The medial rec-
attempt to stabilze the eyes. This condition s tus muscle, which holds the fixating eye n adduc-
known as nystagmus blockage syndrome. tion to "block" the nystagmus, becomes hypertonic,
Congenital (nfantile) nystagmus must be differen- which eventual ly results n esotropa. The mecha-
tiated from other types of nystagmus that occur very nsm is not fully understood, but this association of
early n ufe, such as spasmus nutans. The diagnosis congenital nystagmus and esotropa s known as
s apparent f the nystagmus s associated with an nystagmus blockage syndrome. Often there is an
obvious afferent lesin (e.g., albinism, congenital accommodative element to the strabismus as well.
cataracts, optic atrophy), but efferent etiologies can The syndrome has these main features: First,
present the clinician with a diagnostic challenge. In the onset is in nfancy. Jerk nystagmus precedes
summary, the most distinctive feature of congenital the onset of a variable esotropa that may be alter-
nystagmus, besides its early onset, s ts variability. nating or unilateral. Amblyopia is common,
Congenital nystagmus, although often constantly although some infants appear to cross-fixate so
present, can vary n frequency, amplitude, and type that amblyopia is prevented. Second, there is an
and altrnate between pendular and jerk wave- abnormal head posture, whereby the head s
TABLE8-16. (continued)
23. Gamblin GT, Harper DG, Galent'me P, et al. Prevalence of 41. Cogan DC. Neurology of the Ocular Muscles, 2nd ed.
increased ntraocular pressure in Graves' disease. Evi- Springfield, 111.: Charles CThomas; 1956:87,89.
dence of frequent subclinical ophthalmopathy. N Engl i 42. Leigh R), Zee DS. The Neurology of Eye Movements, 2nd
Med.1983;308:420-424. ed. Philadelphia: Davis; 1991:194,432.
24. Grove AS )r. Evaluation of exophthalmos. N Engl I Med. 43. Mein J, Trimble R. Diagnosis and Management of Ocular
1975;292:1 005-1 01 3. Moti/ity Disorders, 2nd ed. Oxford: Blackwell Scientific;
25. Dallow RL. Evaluation of unilateral exophthalmos with 1991:369-370.
ultrasonography: analysis of 258 consecutive cases. 44. Beck RW, Smith CH. Neuro-Ophtha/mology: A Problem-
Laryngoscope. 1 975;85:1 905-1 918. OrientedApproach. Boston: Little, Brown; 1988:179-782.
26. Enzmann DR, Donaldson SS, Kriss )P. Appearance of 45. Scheiman MM. Optometric finding in children with cere
Graves' disease on orbital computer tomography. } Com- bral palsy. Am J Optom Physio/ Opt/cs. 1984;61 -.321-323.
putAssistTomogr. 1979;3:815-819. 46. Anderson )R. Latent nystagmus and alternating hyperpho-
27. Dyer JA. Ocular muscle surgery in Graves' disease. Trans ria. BrJ Ophthalmol. 1954)38:217-231.
Am Ophthamof Soc. 1978)76:125-139. 47. Leigh RJ, Averbuch-Heller L. Nystagmus and Related Ocu
28. Evans D, Kennerdell JS. Extraocular muscle surgery for lar Motility Disorders. In: Walsh and Hoyt's Clnica/
dysthyroid myopathy. Am I Ophthalmol. 1983;95:767- Neuro-Ophthafmology, 5th ed, vol. 1. Miller NR, Newman
771. NJ, eds. Philadelphia: Lippincott Williams & Wilkins;
29. Kiloh LG, Nevin S. Progressive dystrophy of the external 1998:1462.
ocular muscles (ocular myopathy). Bra/n. 1951;74:115. 48. Stark L, Shults WT, Ciuffreda K), et al. Voluntary Nystag
30. Archer SM, Sondhi N, Helveston EM, Strabismus in mus Is Saccadic: Evidence from Motor and Sensory
infancy. Ophthalmoogy. 1989;96:133-137. Mechanisms. In: Proceedings of the Joint Automatic Con
31. Meldorn E, Kommerell G. Inherited Duane's syndrome: trol Conference. Pittsburgh: Instrument Society of Amer
mirror-like localization of oculomotor disturbance in ica; 1977:1410-1414.
monozygotic twins, J Ped/atr Ophthalmol Strabismus. 49. Zahn JR. Incidence and characteristics of voluntary nys
1979)16:152-155. tagmus. ) Neurol Neurosurg Psychiatr. 1978)41:617-623.
32. Tredici TD, von Noorden GK. Are anisometropia and 50. Ciuffreda K). Voluntary nystagmus: new findings and clin-
amblyopia common in Duane's syndrome? j Pediatr Oph ical implications. Am J Optom Physiol Optics. 1980;57:
thalmol Strabismus. 1985;22:23-25. 795-800.
33. Hotchkiss MG, Miller NR, Clark AW, Creen WR. Bilateral 51. Anderson JR. Cases and treatment of congenital eccentric
Duane's retraction syndrome, A clinico-pathologic case nystagmus. BrJ Ophthalmol. 1953)37:267-281.
report. Arch Ophthalmo. 1980;98;870-874. 52. Nelson LB, Wagner RS, Harley RD. Congenital nystagmus
34. Huber A. Electrophysiology of the retraction syndrome. Br surgery. Int Ophthalmol Clin. 1985)25:133-138.
J Ophthalmol. 1974)58:293-300. 53. Shibasaki H, Yamashita Y, Motomura S. Suppression of
35. Brown HW. Congenital Structural Muscle Anomalies. In: congenital nystagmus. I Neurol Neurosurg Psychiatry.
Strabismus Ophthalm/c Symposium I. Alien )H, ed. St. 1978)41:1078.
Louis: Mosby; 1950:205. 54. Lo C. Brain Computed Tomographic Evaluation of Non-
36. Katz NN, Whitmore PV, Beauchamp GR. Brown's syn comitant Strabismus and Congenital Nystagmus. In:
drome in twins. I Pediatr Ophthalmol Strabismus. ACTA, Twenty-Fourth International Congress of Ophthal
1981)18:32-34. mology, vol 2. Henkind P, ed. Philadelphia: Lippincott;
37 . von Noorden GK. Binocular Vision and Ocular Motility, 1982:924-928.
4th ed. St Louis: Mosby; 1990:389,406-407,417. 55. Mallett RF). The treatment of congenital idiopathic nys
38, Johnson LV. Adherence syndrome: pseudoparalysis of the tagmus by intermittent photic stimulation. Ophthalmol
\ateral or superior rectus muscles. Arch Ophthalmol. Physiol Optics. 1983)3:341-356.
1950)44:870-878. 56. Grisham D. Management of Nystagmus in Young Children.
39. Raflo GT. Blowin and blowout fractures of the orbit: clni In: Problems in Optometry: Pediatric Optometry, vol 2.
ca! correlations and proposed mechanisms. Ophthalmic Scheiman MM, ed. Philadelphia: Lippincott; 1990:496-
Surg. 1984)15:114-119. 527.
\uc\dence of extraocular muscle and era- 57. Harley RD. Pediatric Neuro-Ophthalmology. In: Pediatric
Ophthalmology, 2nd ed. Philadelphia: Saunders; 1983:
^^^^^
thalmology.
PART TWO
TREATMENT
chapter 9 / Philosophies and Principies of
Binocular Vision Therapy
PHILOSOPHIES system that let them know when the eyes were
straight and when they were not, so a conscious
Throughout antiquity, many attempts were made to effort could be made to hold the eyes n alignment.
cure strabismus because t is a disfiguring condi- Binocular visin therapy principies and techniques
tion. The ancient Egyptians recommended exotic evolved out of the attempt to cure strabismus and
ointments such as ground tortoise brain and Orien- were later applied to many other binocular anom-
tal spices rubbed nto the eyes. The classical alies, with significant success. This chapter pre-
Creeks prescribed general body exercise and phys- sents the philosophic foundations for binocular
cal conditioning for relief of eyestrain. In medieval visin therapy, its efficacy with various binocular
Europe, where strabismus was associated with the anomalies, and current principies that guide its
"evil eye" and witchcraft, hats with colored tassels clinical application.
were worn in an attempt to straighten the wander-
ing eye. In the sixteenth century n Germany and
France, "squint masks" were worn, which featured Javal and the French School
eye holes positioned n such a way as to make full- Louis Emile Javal (1839-1907), a French ophthal-
field visin impossible except when the eyes were mologist and professor at the Sorbonne in Pars, is
actually aligned (Figure 9-1). Although squint considered to be the "father of orthoptics" (Figure
masks were cosmetically unattractive, this proce- 9-2). Orthoptics, a traditional term meaning "straight
dure may have been the first effective visin ther- eyes," refers to a training process for eliminating
apy technique for ntermittent strabismus. The strabismus and other binocular visin or oculomo-
masks provided patients with a visual feedback tor anomalies. Javal's work was unique among eye
264 Chapter 9
and other visual ski lis affect performance over ness program. Many students, however, require
time. Optometric visin training includes tech- higher-level management because of visual skill
niques to improve visual, perceptual, and motor anomalies; therefore, optometric visin training
skills. Modern clinicians follow n this holistic clin- falls within the professional spectrum of health
ical tradition, whether concerned with a patient's care activities (.e., the primary care model). Mod-
performance n school, work, or play. For example, ern health care involves concepts of both rehabili-
sports visin training has become a major subspe- tation, when necessary, and preventive holistic
cialty of visin therapy. health conditioning. Primary care optometrists
Binocular visin training evolved within the medi- providing visin therapy services adopt both of
cal model of visin care. Developing within ophthal- these perspectives.
mology as a rehabilitative training technique for
strabismus, orthoptics has much in common with
physical therapy for general neuromuscular disorders PRINCIPIES
or conditions. Vision training techniques were Several principies of visin therapy apply generally
designed initially to re-educate and restore binocular to the practical implementation of a training pro-
visin in strabismics. This approach remains valid gram designed to remedate anomalies of binocu-
and beneficial for many patients, but a number of lar visin. This section will discuss these mportant
optometrists have taken binocular visin training sev- principies and therapeutic options available to the
eral steps further. The term visin therapy is optomet- clinician.
ric in origin and refers to an overall program, usually
including visin training as well as other approaches
(e.g., optics, surgery, hygiene) to remedate or Sequence of Vision Therapy
enhance al I visual skills. When visin therapy s One of Javal's first principies of binocular visin ther-
undertaken strictly to remedate binocular anomalies, apy in cases of strabismus s to address sensory obsta-
the specific term indicating this activity would be cles before dealing with motor dficits. In a general
binocular visin therapy or its synonym, orthoptics. sequence of implementing therapy for strabismus
Approximately one in seven optometric patients, and heterophoria, any significant refractive error
n our experience, has signs or symptoms of defi- should be corrected optically. The results of both
cient binocular visin. The primary care eye exami- cycloplegic and noncycloplegic refractions should be
nation in such patients reveis no strabismus, evaluated to determine the optimum lens prescrip-
disease, or other conditions requiring medical or tion for the patient. We want to emphasize that, in
surgical treatment. The patients simply have a mis- cases of binocular dysfunction, correcting even small
match of their particular binocular visin physiol- amounts of refractive error (e.g., 0.50 diopters [D] of
ogy and their visin demands at school, work, or astigmatism or anisometropia; +1.00 D of hyperopia)
play. They experience visual discomfort, task ineffi- can often help patients maintain a higher level of bin-
ciency, or task avoidance and can be said to have ocular visin. At this point, it is also appropriate to
minimal binocular dysfunctions. Exophoria, hyper- consider the effect of prescribing prisms and lens
phoria, reduced vergences, and hyperopia have all adds for reducing and controlling the deviation. The
been found to occur more frequently among poor clinician should determine whether normal fusin
readers.19 We believe that the primary care optome- can be immediately established using optics at some
trist has the responsibility to identify these problems position in space. The prognosis for a functional cure
and manage them with optics or visin training (or significantly mproves if fusin can be obtained, so
both). The therapeutic goals are binocular visual the extra effort is justified. Table 9-3 lists the general
comfort and efficiency. The goal of this type of ther- sequence of visin therapy for strabismus.
apy s sometimes rehabilitation and other times Amblyopia, eccentric fixation, deficient fixations,
enhancing visin efficiency. Binocular enhance- saccades, pursuits, and accommodation problems
ment training, per se, is a specialized form of physi- all are conditions that require early intervention in
cal education or conditioning. the general sequence of visin therapy. Monocular
We believe that schools also should shoulder training predominates at this stage in the manage-
some of the responsibility of teaching visin ment of strabismus. Nearly all practitioners insist
hygiene and enhancing visual skills through simple that attempts should be made to reduce amblyopia
exercises (see Chapter 16) as part of a physical fit- significantly before the binocular phase of training
Chapter 9 269
However, we recommend that each method be sizes and suppression controls that are built into
used at some point for the sake of generalzation of the target design. Step vergence training can be
skills, f for no other reason. highly effective and efficient because of a rigorous
time frame for the exercise and direct stimulation
Sliding Vergence Training of the dynamic components of fusional vergence
Sliding vergence occurs when second- or third- response latency, velocity, and amplitude.
degree fusin targets are set at a particular accom-
modative demand and are disparated slowly in a Tromboning Vergence Training
continuous manner. The most common example of Tromboning is a colloquial term that describes a
this method is the measurement of fusional ver- method of visin training n which the stimuli to
gence ranges with Risley prisms. Blurpoint, break- both vergence and accommodation are continu-
point, and recovery point are recorded routinely. ously changing. Push-up exercises with a pencil is
This testing method becomes a training technique a common example: The patient attempts to track a
when the patient s instructed to make a conscious pencil smoothly, moving from arm's length to the
effort to hold the targets single and clear for as long binocular nearpoint of accommodation and near-
as possible with repetition. The speed of vergence point of convergence (NPC) and back again to
tracking s not usually the goal, but effort is arm's length. The primary goal is to increase the
directed to increasing the horizontal or vertical near-far bifixation range for clearness or singleness
vergence ranges as well as the smoothness and with the particular target or instrument assigned by
accuracy of vergence responses. The amblyoscope the therapist. The patient records the best daily
and Mirror Stereoscope are particularly suited to nearpoint of accommodation and NPC achieved
this method of training in cases of strabismus; split during the training session. Speed of vergence
Vectograms and Tranaglyphs often are used in het- tracking can be an auxiliary goal, although it usu-
erophoric cases. The training targets typically con- ally is not; increasing smoothness and stamina,
tain suppression controls. If suppression occurs however, are. For patients with eso deviations,
during the training technique, disparation s tem- tromboning targets on a Brewster Stereoscope is
porarily stopped and suppression s broken before particularly challenging. Paradoxically, as the
proceeding. To monitor progress, the patient's best accommodative stimulus increases, so does the
vergence ranges each day are recorded at the end stimulus to fusional divergence. Tromboning tech-
of the training session. niques can be conveniently used with most hand-
held vergence targets (e.g., eccentric circles, red-
Step Vergence Training green circles, Minivectograms). Tromboning as a
Step vergence refers to the phasic introduction of a method of vergence training s popular with
vergence stimulus in which the stimulus to accom- many primary eye care doctors.
modation s fixed. A common example s the use
of lose prisms: The patient's attention s directed Jump Vergence Training
to a target at a particular viewing distance. A lose Jump vergence (sometimes incorrectly called jump
prism of an appropriate amount is placed before ductions and occasionally confused with step ver-
an eye. The patient may temporarily see a double gence) is another popular method of vergence
image and should make a conscious effort to fuse training. Jump vergence occurs when a patient
the images quickly into one. As soon as the images altrnales fixation between two vergence targets
are joined, the prism is removed or a larger step is placed at two different distances in space. The
introduced. In this case, the primary goal s to stimuli to both accommodation and vergence
increase the speed of step vergence responses. The change in a phasic manner. For example, a patient
patient usually counts and records the number of can be asked to altrnate fixation as quickly as
steps completed during an assigned time interval, possible between a televisin screen at far and a
(e.g., 1 or 2 minutes). pencil tip positioned at approximately the patient's
Additional goals can be to mercase the size of NPC. The patient counts the number of cycles
the step responses and to ncrease stamina by completed during a commercial break n a pro-
extending the training time. Another common gram and attempts to ncrease that number with
training instrument, the Brewster Stereoscope, has practice. Physiologic diplopia can be used as a
many stereograms with step demands of various control on suppression. Besides speed, the goals
272 Chapter 9
include increasing the near-far amplitude of the the permanence of results requires training at a
jump and building stamina. )ump vergences can reflexive level of functioning. Certainly, visin
be used with many training instruments and most training builds conditioned reflexes through repeti-
hand-held targets. tion. Sufficient repetition is fundamental to acquir-
ing any motor skill in athletics, physical therapy, or
tsometric Vergence Jraining visin therapy. We also believe that generalization
Isometric exercise occurs when the tensin in a of vergence training is an important means of
muscle increases without physical shortening of extending the training effect to the required reflex-
the muscle. This can be done with extraocular ive level.
muscles by increasing a stationary, tonic load on
the fusional vergence system using prisms, added
lenses, or fusin targets with base-in or base-out Office Training versus
demands. For example, base-out Fresnel prisms Home Training
can be applied to the spectacle lenses of an exo- Most visin training programs for strabismic and
phoric patient and worn daily for a prescribed heterophoric conditions involve some combina-
period. In this way, the demand on fusional con- tion of home training and office training visits, but
vergence is increased. Similarly, a minus-add or a practitioners vary greatly in the relative emphasis
base-in clip-over can be prescribed for an eso- of the two. We have no strong recommendations in
phoric patient to wear during the morning hours, this regard, because so many variables are involved.
to increase fusional divergence. Another example However, it may be helpful to review some of the
would be to require an esotropic patient to hold a important considerations.
maximally diverged position on an amblyoscope The more severe the condition, the greater is the
using fused third-degree targets for 5 minutes at a need for office training visits. Office visits directly
time. Experiments by Vaegan21 have shown that supervised by a doctor or visin therapist are usu-
isometric vergence exercises of this type result in ally more effective, efficient, and motivating than
large and sustained increases in vergence ranges are home training sessions. This principie applies
after a short training period. Although effective, to patients of all ages. Moreover, when a particular
this method of vergence training must be carefully in-office technique proves too difficult or ineffec-
monitored by the therapist, because a patient may tive, it can be changed immediately to a more
experience intolerable symptoms or the demand effective one. Most patients with strabismus and
may prove to be too large to maintain bifixation. amblyopia make better progress with frequent
Besides increasing vergence ranges, isometric office training visits, ideally two or three times per
exercise is effective in building stamina. week, supplemented by home training.
We have found that most cases of heterophoria,
Application of the Var/ous accommodative dysfunction, and minimal binocu-
Vergence Jraining Methods lar disorders can be successfully managed on a
Each method of vergence training has a logical home training basis when supplemented with
application for particular types of vergence dys- weekly in-office visits. The patient must be suffi-
functions. These will be described in subsequent ciently mature and motivated to complete at least
chapters, but usually all five methods can and five home sessions per week, although seven train-
should be used, in our opinin, at some point ing days per week is the stated goal. Consistent
within a sequence of training techniques. Gener- and frequent repetition produces the best results. If
ally speaking, we believe a training program the patient is no more than 6 years od, office visits
should emphasize the phasic methods of step and (two or more times per week) may be needed for
jump vergence. Daum22 found that phasic tech- effective treatment despite good parental involve-
niques expanded convergence and divergence ment at home. School-aged children routinely
ranges more effectively than did the tonic methods need direct adult supervisin, usually that of a par-
of tromboning and sliding vergence. We believe ent. In some cases, a friend, relative, or paid tutor
there is valu in using all five methods of vergence can be substituted. The home training supervisor
training, if possible, to promote the general i zation (coach) ideally should attend most office visits to
and permanence of the training effect. Even though receive proper instructions from the doctor or
conscious effort is used to improve vergence skills, visin therapist and directly observe the tech-
Chapter 9 273
2. Cantonnet A, Filliozat J. StrabismusIts Re-education: 17. Ogle KN. Researches n Binocular Vision. Philadelphia:
The Physiology and Pathology of Binocular Vision. Lon- Saunders,1950.
don: Wiseman; 1934. 18. Ogle KN, Martens TG, Dyer JA. Oculomotor Imbalance
3. Gibson HW. Textbook of Orthoptics. London: Hartn n Binocular Vision and Fixation Disparity. Philadelphia:
Press; 1955:289-290. Lea & Febiger; 1967.
4. Worth C. SquintIts Causes, Pathology, and Treatment. 19. Grisham JD, Simons H. Perspectives on Reading Disabili-
Philadelphia: Blakiston's; 1921. ties. In: Pediatric Optometry. Rosenbloom A, Morgan M,
5. Richards W. Anomalous stereoscopic depth perception. J eds. Philadelphia: Lippincott; 1990:518-559.
OptSocAm. 1971;61:410-414. 20. Ciuffreda KJ, Levi DM, Selenow A. Ambiyopia: Basic and
6. Chavasse FB. Worth's Squint, the Binocular Reflexes and Clinical Aspects. Stoneham, Mass.: Butterworth-Heine-
the Treatment of Strabismus, 7th ed. Philadelphia: Blaki mann; 1991:411-493.
ston's; 1939. 21. Vaegan. Con and divergence show large and sustained
7. Lyle TK, Bridgeman CJ. Worth and Chavasse's Squint mprovement after short isometric exercise. Am J Optom
The Binocular Reflexes and the Treatment of Strabismus, PhysiolOpt. 1979;56:23-33.
9th ed. London: Bailliere, Tindall and Cox; 1959. 22. Daum KM. A comparison of the results of tonic and pha-
8. Duke-Elder S. Ocular Motility and Strabismus: Vol 6, Sys sic vergence training. Am J Optom Physiol Opt. 1983;60:
tem of Ophthalmology. London: Henry Kimpton; 1973: 769-775.
245. 23. Daum KM. The course and effect of visual training on the
9. Sheard C. Dynamic Ocular Tests. Columbus, Ohio: vergence system. Am J Optom Physiol Opt. 1982;59:
Lawrence Press; 1917. 223-227.
10. Sheard C. Zones of ocular comfort. Trans Am Acad 24. Wilson JAR, Robeck MC, Michael WB. Psychological
Optom. 1928;3:113-129. Foundation ofLearning and Teaching. New York: McGraw-
11. Fry GA. An experimental analysis of the accommodation- Hill; 1974.
convergence relation. Trans Am Acad Optom. 1937;14: 25. Klausmeier HJ, Ripple RE. Learning and Human Abilities:
402-414. Educational Psychology, 3rd ed. New York: Harper &
12. Fry GA. Further experiments on the accommodation-con- Row; 1971.
vergence relationship. Trans Am Acad Optom. 1938;12: 26. Hershey GL, Lugo JO. Livng Psychology: An Experimen
65-74. tal Approach. London: Macmillan; 1970.
13. Morgan MW. Accommodation and ts relationship to 27. Grisham JD, Bowman MC, Owyang LA, Chan CL. Ver
convergence. Am J Optom Arch Am Acad Optom. 1944; gence orthoptics: validity and persistence of the training
21:183-195. effect. Optom Vis Se i. 1991,-68:441-451.
14. Morgan MW. Analysis of clinical data. Am J Optom Arch 28. Pantano F. Orthoptic treatment of convergence insuffi-
Am Acad Optom. 1944;21:477-491. ciency: a two year follow-up report. Am Orthopt J.
15. Hofstetter HW. Zone of clear single binocular visin. Am J 1982;32:73-80.
Optom Arch Am Acad Optom. 1945;22:301 -333,361 -384. 29. Griffin JR, Bui K, Ko C. Durability of Vision Therapy.
16. Hofstetter HW. Orthoptics specification by a graphical Research thesis. On file in the MB Ketchum Memorial
method. Am J Optom Arch Am Acad Optom. 1949;26: Library, Southern California College of Optometry, Fuller-
439^44. ton, 1991.
chapter io / Therapy for Ambiyopia
<
Final Results 320
280 Chapter10
This discussion of amblyopia therapy presupposes modation; (4) breaking suppression and building sen-
that an accurate differential diagnosis has been sory and motor fusin; and (5) improving VA to
established (see Chapters 5 and 6) and that the normal or near-normal levis. If the patientwith func-
patient's visual acuity (VA) loss is not caused by tional amblyopia does not respond to the use of
psychogenic, structural, or pathologic processes. optics, occlusion, and conventional visin training,
The patients with whom we are concerned here trien pleoptics and other special techniques may be
have primarily a functional type of amblyopia (i.e., tried in a last attemptfor visual rehabilitation.
soametropic, anisometropic, strabismic, or image In this chapter, we discuss the use of amblyopia
degradation amblyopia) and a realistic chance for remedial methods in sequence, their advantages
either improvement or cure with visin therapy. and disadvantages, and their efficacy, and we
Besides optical correcton, the most commonly address several important issues in the overall
used therapeutic method for amblyopia is direct implementation of amblyopia therapy. Table 10-1
occlusion. Many cases are managed successfully lists the general sequence of amblyopia therapy
using only these two passive therapeutic options. and training objectives; this sequence serves as the
Active visin therapy often is recommended to speed organizational structure for our discussion. Spe-
up the rehabilitation process and to increase the cific training techniques are numbered for easy ref-
chance of success. Some intermedate visin training erence (T10.1-T10.23) as they are introduced.
goals are (1) training steady central fixation; (2) build-
ing accurate pursuit and saccadic eye movements;
(3) increasing the amplitude and facility of accom-
MANAGEMENT OF
REFRACTIVE ERROR
TABLE10-1. Sequence of Amblyopia Therapy Correction of any significant refractive error, par-
ticularly anisometropia and astigmatism, is funda-
mental to effecting a cure of functional amblyopia.
1. Correction of the full refractive error The patient's refractive error is often an important
2. Occlusion therapy (if not the most important) factor in the etiology of
3. Eye-hand coordination training amblyopia. Successful, efficient, and enduring visual
4. Visual resolution training rehabilitation requires the elimination of all
5. Training to establish steady central fixation with amblyogenic factors. Even small amounts of refrac-
f oveal tag tive error (e.g., 0.75 diopters [D] of anisometropia
a. Train central fixation and astigmatism) can be significant in some cases.
b. Train steady fixation The clinician should remember that there is often a
c. Train saccadic accuracy latent component to hyperopia that may need to
d. Train foveal localization be revealed with cycloplegia. We believe the
e. Train pursuit accuracy importance of correcting the full refractive error
6. Auxiliary therapy for eccentric fixation (if neces- cannot be overemphasized. If a patient continually
sary): pleoptics, red filter, and inverse prism refuses to wear a needed optical correction or
7. Training of accommodation demonstrates persistent noncompliance, the doc-
8. Establishment of normal binocular visin (if possi- tor may be forced to dismiss the patient from
ble and prudent) amblyopia therapy and reschedule only when
a. Break suppression cooperation can be fully enlisted. An alternative,
b. Train monocular fixation and resolution of the however, is pharmaceutical treatment, which
amblyopic eye under binocular conditons
requires relatively less cooperation (as discussed
c. Extend the range of sensory and motor fusin
later in this chapter).
to the mximum degree
Many practitioners find that, for various reasons,
d. Recommend surgery for strabismus (if necessary)
frequent changes in the lens prescription may be
9. Prescription of appropriate maintenance program
(e.g., periodic occlusion, retainer home traning, necessary for the amblyopic eye.1 Objective cyclo-
monovision lenses) plegic refractive procedures usually are required
10. Periodic office visits to monitor for regression and that may lack sufficient accuracy, depending on
provide follow-up management the skills of the clinician and other factors. The
refraction may not be precisely on the visual axis
Chapter10 281
due to a strabismus or eccentric fixation (EF). Also, vidual relies on the VA of the least ametropic eye.
i younger chdren, the actual refractiva error may Contact lenses are cosmtica! ly more acceptable,
diange over short periods. Therefore, clinicians and cosmesis is good because the eyes are not dif-
should frequently recheck and refine an amblyopic ferentially magnified to an observer. Also, there is
patient's refractiva status, possibly once monthly n no induced prism effect with the contact lenses,
same cases. As VA improves, subjective refractive because the optical centers of the lenses remain
todiniques can become more refined for an exact relatively centered with eye movements; in con-
fcns prescription. Patients or parents must under-5 trast, vertical prismatic effects are induced in spec-
stand that several lens changes may be necessary tacle lenses of unequal power n upward and
spart of a visin therapy program for amblyopia. downward positions of gaze, for example. Contact
Some clinicians are conservative when prescrib-ing lenses for hyperopia should also be seriously con-
for the full amount of hyperopia, astigmatism, and sidered in cases of esotropic amblyopia, particu-
anisometropia. Anticipating that the patient larly if there is a large accommodative component.
aiay not adapt easily to the new prescription lenses, Disadvantages of contact lens wear, however, must
iey reduce the optical correction by some amount be weighed against these advantages. Prisms cannot
ffcased on their experience or previous training. In be effectively used with contact lenses yet may be
lanaging binocular visin cases in general, and | necessary in the overall management of stra-bismic
amblyopes in particular, we believe this approach amblyopes. The handiing requirements, lens care
iBually is not warranted. Because the amblyopic responsibilities, expense, and psychological
eye usually is suppressed to some degree, adapta- adjustment to wearing contact lenses can al I become
tion symptoms related to a new optical correction overriding contraindications n some cases. Because
afeen are less severe as compared to those in there are frequent lens changes in cases of amblyopia
patents having good binocular visin. Neverthe- (particularly children), we often prefer initially to cor-
less, forewarning a patient of potential adaptation rect the refractive error with spectacles. After a stable
symptoms can provide the motivation to endure refraction s found and VA has sufficiently mproved
some temporary discomfort, if t occurs. in the amblyopic eye, contact lens wear may be rec-
The initial steps of amblyopia therapy usually ommended for long-term management. If, however,
Biwolve occlusion, n addition to full optical correc- a patient resists wearing spectacle lenses after
tion; binocular adaptation symptoms are therefore repeated attempts, then contact lens wearing neces-
ot mmediate problems. We have seen many mildly sarily becomes the preferred option.
amblyopic patients, particularly in cases of isoame-
fcopic and meridional amblyopia, achieve a com-
plete functional cure, with 20/20 (6/6) VA, by simply OCCLUSION PROCEDURES
wearing the full spectacle correction over a period of
Several variables are nvolved n the management of
atew months, without the necessity for occlusion or
occlusion therapy for amblyopia. Many forms of
active therapy. Pickwell2 reported curing 7 of 14 ani-
occlusion have been recommended to remedate
sometropic amblyopes (8 years of age, on average)
amblyopia (Table 10-2 and Figure 10-1). Patching of
merely by prescribing the full lens correction. Ambly-
the nonamblyopic eye s called direct occlusion, and
opia is often abated, even n adults, as a result of
patching of the amblyopic eye s inverse occlusion.
dear retinal imagery. For these reasons, we recom-
Occlusion can be total or partial; total usually means
mend immediate and full optical correction, when
that the entire visual field is blocked out (e.g., ban-
feasible, of any significant refractive error n both the
dage occluder or a prate patch), whereas partial
nonamblyopic and the amblyopic eye.
occlusion means that only part of the visual field is
In many cases of modrate or marked ani-
occluded (e.g., a sector occluder). An occluder can
sometropia, the clinician should consider correct-
be opaque (blocking out all light) or translucent, to
ing the refractive error with contact lenses. Contact
degrade form visin. Each type of occlusion has its
lenses have several advantages over spectacles.
own clinical merits and disadvantages.
The patient may be more likely to wear the pre-
scription lenses. Children frequently object to
wearing glasses in general but, n addition, the ani- Direct Occlusion
sometropic patient usually notices no mmediate The oldest and most popular therapy for amblyo-
benefit in acuity with the glasses because the indi- pia is direct, opaque, total occlusion (e.g., patch-
282 Chapter10
c. Colored filters
d. Translucent lenses (frosted or etched) 4. Patching tendsto breakdown the pattern of
e. Blurring (spectacle lens, contact lens, drugs) suppression associated with both anisome-
C. According to wearing time tropic and strabismic amblyopia.
1. Constant (full-time) 5. In cases of strabismic amblyopia, occlusion
2. Intermittent (part-time) prevents the development or reinforcement
of anomalous retina! correspondence (ARC).
D, According to which eye s occluded
1. Drect {patching the better eye) There is general agreement about initially pre-
2. Indrect (patching the amblyopic eye) scribing full-time direct occlusion for the infant
3. Altrnate (switching the patch from one eye to and preschooler who has constant strabismus. In
the other in a prescribed manner) cases of anisometropia without strabismus, or
only intermittent strabismus, part-time (3-6
hours per day), opaque, direct occlusion usually
is recommended along with full-time spectacle
ing of the good eye with a bandage). In 1 743, de correction of any significant refractive error
Buffon, a French naturalist, stretched gauze over when the amblyopic acuity is 20/100 (6/30) or
a ring of whale bone to make an occluder for the better. This part-time schedule of occlusion pro-
dominant eye. 3 Such direct occlusion forces the motes development of monocular skills of the
patient to use the amblyopic eye (the so-called amblyopic eye and still allows for development
lazy eye) perhaps for the first time (Figure 10-2). of normal binocularity when the patch is
Assuming significant refractive error of the removed. Patients with deep amblyopia (VA
amblyopic eye has been corrected with lenses, worse than 20/100) usually require relatively
direct occlusion has several beneficial physio- long periods of daily occlusion. Most individuis
logic effects: during infancy develop normal acuity in the
1. The patient is forced to practice monocular amblyopic eye within 1 or 2 months of adher-
oculomotor skills of fixation, pursuits, sac- ence to this schedule, but preschool children
cades, and accommodation. may take longer, 2-4 months. Long-term, con-
2. The faulty localizaron associated with EF is stant wear of the spectacles to correct ani-
broken down through practicing correct sometropia is required in all cases to prevent the
eye-hand coordination. recurrence of amblyopia. If, however, a young
3. Proper sensory stimulation of the amblyopic child has constant strabismus, with or without
eye is achieved and allows for the develop- anisometropia, initial occlusion should be con-
ment of cortical receptive field organization stant, total, and opaque. The clinical guideline
(Le., in young children who neurologically recommends that if there s constant strabismus
have sensory plasticity). at all distances, constant patching is appropriate.
Chapter10 283
Bandage Optidude, Elastoptast Total occlusion; convenient; Some allergic reactions to adhe-
(opaque) effective; child and adult sizes sive; sometimes, unaccept-
able cosmesis
Tie-on Prate patch, elastic patch Total occlusion Lose; moveable; difficult to
wear with spectacles
Clip-on Clips onto spectacle frames, Parta! occlusion possible Children peek around the
sizes 32-50 occluder; can be too easily
removed by a child
Translucent Magic Tape, nait polish Degrades form resolution of Children tend to peek around
coating on spectacle nonamblyopic eye; accept-able lens
lens, f rosted lens, optical cosmesis
blur
Filters Neutral-density Breaks suppresson; allows some Effective visual acuity improve-
fusin Convenient; effective; ment uncertain Difficult for
Contact tens Opaque soft lens accept- children to handle;
able cosmesis requires cleaning; expensive
Chapter10 285
mus, the doctor can prescribe a frosted lens or the way. Johnny's patch may provide a good opportu-
optical blur method of penalizaron. Using such pro- nity for the teacher to talk about the eyes and the
cedures, the nonamblyopic eye's image is degraded "wonders of visin."
sufficiently to change fixation preference to the Teenagers vary considerably in their compliance
amblyopic eye without completely dissociating the with patching. Some are very mature and make a
eyes, thus minimizing disruption of binocular visin. personal choice to improve their visin regardless
The amount of part-time opaque occlusion rec- of comments from their peers. Others are abso-
ommended for anisometropic amblyopia is based lutely terrified of "looking different." In the latter
on the depth of amblyopia and the extent of nor- cases, a contact lens occluder may be the only
mal binocular visin. Deep anisometropic ambly- realistic alternative to enlist cooperation with
opia (20/200 or worse) with deep suppression and visin therapy. Another alternative that can be pro-
little binocular visin may initially require full-time posed to self-conscious patients is to initiate the
occlusion. If the amblyopia is modrate (e.g., 207 patching program during vacations from school,
100 [6/30]) and peripheral fusin with stereopsis when peer interactions may be more controlled.
exists, then 3-6 hours per day of direct occlusion
may be appropriate.
Patching Progress
In most cases of functional amblyopia, there is an
Motivation and Patching initial rapid increase in VA and improved fixation
Management pattern of the amblyopic eye in response to con-
Amblyopes do not regard the wearing of a patch as ventional direct occlusion. Most mprovement
fun. If the VA is 20/100 (6/30) or worse, the patient occurs during the first 3 months. In a study of 350
often feels visually disabled. Therefore, it s a good amblyopic children, Oliver et al. 5 reported an
dea to build a young patient's confidence before a average increase of approximately four lines of VA
patch is worn. The patient should first be able to on Snellen charts during the initial 3 months of
demnstrate proficiency n gross motor tasks. Other- direct occlusion. Approximately one additional
wise, he or she will experience frustration and will line of mprovement occurred n the next 3-month
most certainly reject the occluder. Parents and period, and only marginal mercases accrued there-
teachers should not allow the child to particpate after. A recent report by Cleary6 confirmed that the
in potentially dangerous activities while being optimum results of occlusion occurred n the first 6
directly occluded. Chiidren usually cooperate with months.
patching to please the parents and, occasionally, After a patient begins to follow the occlusion
the doctor; it is important for all involved adults to schedule, regular office visits are indicated to moni-
give praise, support, and even rewards for compli- tor progress, build motivation, and coordnate
ance. Just as adults usually require rewards of visin training techniques that shorten the total ther-
some kind in exchange for difficult, unpleasant apy time. We suggest weekly office visits nitialiy, to
work, a child's efforts must be acknowledged. ensure that the occluson and visin training are
Many elementary school children are embar- correctly applied and effective. If a plateau n acuity
rassed to wear a patch because of questions and or fixation pattern occurs for 4 weeks, we suggest
comments from their peers. We have found it help- changing the thrust of the therapy. If the patient
ful for the child with a patch to practice answering develops steady EF, the clinician may consider
questions about t n the doctor's office before con- switching to inverse occlusion, applying different
fronting such questions on the playground. active therapeutic approaches (e.g., afterimage [Al]
transfer techniques), applying pleoptics, or using
Sally: "Johnny, why do you wear that patch?" red-filter techniques, monocular prism methods, or
a monocular telescope. (These approaches are
Johnny: "The patch is going to make my other explained later n this chapter.)
eye super strong so I can see really well with If, however, there is no progress n VA or the fix-
it. The doctor says only I can wear it." ation pattern after 2 or 3 weeks of occlusion with
full patient compliance, the clinician should sus-
It may also be helpful for the teacher to discuss the pect either amblyopia of arrested development or a
patch with the class, f this is done in a positive possible pathologic etiology. In such cases, prog-
286 Chapter10
nosis needs to be modified accordingly. However, In an excellent review article, Birnbaum et al.13
f there has been a significant improvement after a demonstrated that the age of treatment was not as
week or two of patching, both the patient and cli- important a factor in determining success of ambiy-
nician should be encouraged; the successful thera- opia therapy as once was believed. These investiga-
peutic approach should be continued until tors analyzed 23 studies with a total sample size of
mximum improvement occurs. more than 1,000 amblyopic patients of all ages. The
overall success rates for adult treatment compared
favorably with those for children. Using a success
Efficacy of Occlusion and criterion of 20/30 VA, there was no significant differ-
Ambiyopia Therapy ence between four age groupings. Children younger
As a therapeutic method, patching an eye is easy, than 7 years and older patients (at least 16 years)
econmica!, and requires only minimal involve- both had a success rate of approximately 40%,
ment by the doctor. For more than 200 years, although, using the success criterion of four lines of
direct occiusion has been, and remains, the stan- improvement on a Snellen chart, the children were
dard treatment for ambiyopia. According to an more successful (57% versus 42%). Nonetheless,
extensive literature review by Garzia, 7 the suc- 42% is not a bad success rate for ambiyopia treat-
cess rates (i.e., achieving 20/40 VA) range from ment for adults. Three comprehensive studiesa
40% to 80%, with noncompliance of patching large survey of 368 amblyopic patients,14 a detailed
being a significant reason for failure. Dorey et al. 8 analysis of 19 older anisometropic amblyopes,15
recently reported on 39 children who failed to and a study of 36 compliant older children16are
make progress with patching at home. However, consistent with the conclusions of Birnbaum et al.13
after 5 days of a supervised occiusion rgimen in Age of treatment seems only a minor factor in the
a hospital, most of these children made signifi- success rate for ambiyopia remediation. Clinicians
cant gains. should no longer be surprised to hear about adult
We propose the following generalities: Successful amblyopes who regain visin due to visin therapy.
treatment of meridional and low to modrate Also, ambiyopia sometimes is abated by an
isometropic amblyopias is perhaps easiest, because acquired loss of acuity in the nonamblyopic eye
the ambiyopia is usually mild, 20/60 or better.9'10 (e.g., from a developing cataract17 and macular
These patients often respond successfully over time degeneraron18). (Refer to Chapters 5 and 6 for dis-
simply to correction of the refractive error. Anisome- cussions of the relationship between prognosis and
tropic ambiyopia often improves quickly with full age of onset of ambiyopia, duration, and age of
correction of the refractive error, occiusion, and treatment.)
antisuppression training, f there is no EF. Kutschke Although the overall success rate does not
et al.11 reported an 82% success rate (using the 20/ change much with age, the length of treatment
40 or better acuity criterion) for their clinical series does increase; older patients generally take longer
of 124 anisometropic amblyopic patients. They to achieve best results. In most cases of functional
found that myopic and compound myopic, astig- ambiyopia, VA can be improved at any age, but the
matic, anisometropic patients had the poorer visual physiologic changes occur more slowly with
outcomes. By comparison, strabismic ambiyopia of advancing age. The public suffers from much mis-
long standing frequently is more difficult to treat, in information about ambiyopia. It is still commonly
part because EF usually is well established. Gener- believed that ambiyopia cannot be treated suc-
ally, when strabismus and anisometropia coexist as cessfully after age 5 or 6 years. It is more than a
amblyogenic factors, the prognosis is even worse. coincidence that the rate of patient compliance
Of al I amblyopic patients, those with deprivation with patching decreases significantly when the
ambiyopia from early childhood are the most diffi- child enters school, presumably due to the lack of
cult to cure (e.g., congenital cataract or ptosis). direct parental supervisin. Oliver et al. 5 found
Prognosis in such cases is guarded. It is important to that compliance with patching decreased from
emphasize that even though 20/30 acuity or better 72% among preschool children to 47% for chil-
in an amblyopic eye is a good clinical goal, patients dren ages 8-12 years od. Most visin therapists
often appreciate any improvement in VA. A com- know from experience that it is more difficult to
mon prognostic factor, regardless of type of ambiyo- enlist compliance for patching from school-aged
pia, is the depth of acuity loss.12 children as compared with preschoolers or adults.
Chapter10 287
The most important barriers to successful amblyo- or optical means to blur the preferred eye so that
pia therapy past age 5 years are more psychologi- use of the amblyopic eye is favored. A few clini-
cal and managerial than physiologic.19 Clinicians cians prefer penalization to bandage occluders
must continu making the recommendation for during the initial stage of amblyopia therapy, but
preschool treatment of amblyopia primarily most do not consider using these techniques until
because t can be done with more acceptance and conventional total occlusion methods have been
will help in the establishment of normal binocular tried and failed. However, penalization becomes
visin; however, they should also emphasize that the preferred treatment option when there is latent
many patients with amblyopia can be treated suc- nystagmus, intermittent strabismus, or an allergic
cessful ly at any age. reaction to the bandage adhesive.
Vision training to remedate amblyopia and EF is
an important and effective adjunct therapy to Penalization Methods
occlusion. There are several detailed case reports Each penalization method has a place n the man-
n the literature of patients who, unsuccessful with agement of some amblyopic patients. Generally
direct occlusion, responded successfully to visin speaking, these methods are used more often n
training.1'15'20"22 Cenerally speaking, the reported strabismic amblyopia than n anisometropic ambly-
success rate in studies that augmented occlusion opia, with the exception of farpoint penalization,
therapy with active therapy (e.g., visual tracking, which has been used with both types f normal
foveal tag, and antisuppression techniques) are fusin s the goal.
usually higher (70% or better) than those using
occlusion alone.23"28 One study by Francois and Penalization without Spectacles
James28 directly compared results of one group of When a child s totally uncooperative with either
amblyopes using occlusion alone (N = 100) with conventional occlusion or spectacle wear, pharma-
another group (N = 100) treated with occlusion ceutical penalization provides the practitioner with an
and visin training. The final success rates were the effective but somewhat risky alternative. Atropine (1 %
same, but the visin training group took signifi- drops or salve) is nstilled in the nonamblyopic eye
cantly less time. Another comparative study by once daily whereas a miotic (e.g., 0.025% diisopropyl-
Leyman26 of 62 amblyopes reported a success rate fluorophosphate, 0.06% echothiophate iodide, or
of 72% for occlusion alone, 50% for pleoptics 1% pilocarpine drops, twice daily) is used n the
alone, and 93% for a combination group of occlu- amblyopic eye. There is some pain associated with
sion and monocular and binocular visin training. instillation of miotics, so some clinicians recom-
One reason for the higher success rate when visin mend applying the ointment or drops when a
training augments optical correction and occlusion young child is asleep or at bedtime. The cyclople-
is that the overall treatment time is reduced by as gic effect of the atropine prevents the patient from
much as 50%.27-28 Patient compliance with patch- focusing for nearpoint objects with the nonambly-
ing tends to diminish over time, so anything that opic eye, whereas the miotic pupil increases the
can be done to speed progress promotes the best depth of field of the amblyopic eye. Like a pinhole
overall outcome. We strongly recommend that, in camera, the amblyopic eye has a clear image for
addition to occlusion, amblyopic patients be given objects for most distances. Spectacle correction of
at least some of the visin training techniques the refractive error, therefore, may not always be
described later in this chapter. necessary using this method. The clinician does
Besides acuity mprovement, additional benefits need to monitor the patient closely for drug side
of amblyopia therapy include increases n stereopsis effects, particularly with this method, because of
in approximately half of anisometropic patients29'30 their common occurrence with the protracted use
and improvement in monocular and binocular con- of miotics (e.g., iris cysts, brow pain, headaches,
trast sensitivity in all types of amblyopia.31 conjunctival rritation, anterior subcapsular cata-
ract). The mximum ncrease of acuity in the
amblyopic eye usually occurs at between 3 and 6
Penalization months of drug therapy, depending primarily on
One alternative to standard total occlusion when a the patient's age and depth of amblyopia. Signifi-
child refuses to wear a patch s some form of cant improvement of acuity has been reported in
penalization. Penalization refers to the use of drugs more than 75% of patients, irrespective of age.32
288 ChapteMO
00
+3 D AddI
I +3 D Add
1% Atropine 1% Atropine
FIGURE 10-3Near penalization with cycloplegia. FIGURE 10-5Far and near penalization of the nonambiyopic eye with
cycloplegia and a plus lens. Only a small depth of field is available to
the nonambiyopic left eye (at the 30-cm distance), with blurring of
nearer objects because of paralysis of accommodation and blurring o
Near Penalization farther objects that are beyond the focal distance of the lens.
Farpoint Penalization
If an uncooperative amblyopic patient has ani-
full hyperopic
sometropia or intermittent strabismus, and fairly
good binocular visin is preserved, penalization at
far is the method of choice. The method works best
when amblyopic reduction in VA is mild to modr-
ate, 20/100 or better (Figure 10-5). Atropine (1%
drops or salve) is nstilled daily in the nonambiy-
FIGURE 10-4Total penalization
with cycloplegia that is used with highly hyperopic amblyopes. (Rx = opic eye, and a +3.00-D single-vision add s
treatment.) placed before that eye. The nonambiyopic eye,
ChapteMO 289
penalization, the acuity mproved on average from ered negligible; furthermore, higher dosages do
20/61 to 20/40. The percentages of patients whose not yield additional benefits.50
VA improved were 77% and 76%, respectively. In This line of research looks promising but, as yet,
the atropine group, a variation of near penalizaron this treatment seems impractical for general clini-
was applied: The full hyperopic correction was cal application. However, f a clinician finds that
given, and atropine drops were nstilled daily in progress has stalled using conventional patching
the nonambiyopic eye. The ambiyopic eye fixated and visin training, levodopa administration may
near targets without the benefit of a plus-lens add. yield visual enhancement that would otherwise be
Repka and Ray42 reported no cases of occlusion impossible. Conventional visin therapy could
amblyopia in either group. then be reintroduced in the hope of maintaining
Generally speaking, we believe the outcomes the achieved results.
with penalization are comparable to those using
conventional direct occlusion. Parent and patient Red-Filter Therapy and Occlusion
compliance is superior with penalization, but the
When occlusion procedures do not produce the
use of atropine for long periods, often 1-3 years,
desired increase in VA or f unsteady EF becomes
places the patient at risk for undesirable side
steady and eccentric, red-filter therapy may be
effects. Recently, a clinical series of 89 strabismic
considered as an alternative method to promote
amblyopes was reported in which optical penal-
foveal fixation. We do not recommend using this
ization without atropine resulted n 93.5% of the
technique initially, because most patients find t
patients achieving 20/30 VA or better with a mean
cosmtica!ly unacceptable and will not cooperate
duration of treatment of 2.3 years.43 Overcorrec-
for more than a few hours daily. The method
tion of +2.00 D to +2.50 D was used, and patients
requires the patient to wear a total occluder on the
ranged in age from 2.0 to 10.5 years, the mean
nonambiyopic eye while a red filter s worn on the
being 5.2 years. The author emphasized that this
ambiyopic eye.
penalization method s simple, safe, and effi-
A Kodak gelatin Wratten filter No. 92, which
cient.43 France and France44 stated that optical
excludes wavelengths shorter than 640 nm, was
penalization has a good record of maintaining the
advocated by Brinker and Katz.51 However, this
improvement in VA after conventional occlusion
material is brittle and dissolves easily in water,
has been used and, n many cases, produces fur-
thereby destroying its optical quality. Less expen-
ther gains.
sive red transparent vinyl or a regular ruby Kodal-
oid filter can be used effectively.52 The red filter s
Levodopa Treatment applied to the surface of a spectacle lens, and the
nonambiyopic eye is total ly patched with a ban-
Over the last decade, a series of clinical reports
dage occluder. The theory behind a red filter's pro-
have noted mprovement of visual functions of
amblyopes who were administered levodopa or motion of foveal fixation s that the fovea has a
similar centrally acting medications. 45 Although higher proportion of red-sensitive cones as com-
pared with eccentric points; henee, the fovea s
the specific actions of these drugs on visual func-
favored for fixation.
tion have not been identified, several studies46'47
von Nloorden53 found this method to be effec-
document improvements in VA (approximately one
and a half Snellen lines, on average), contrast sen- tive n some ambiyopic patients. The fixation pat-
tern of the ambiyopic eye should be closely
sitivity, and visually evoked potential amplitudes
(approximately 30%), and decreased suppression monitored by visuoscopy, and 1-3 months of
scotomas. The medications typically are adminis- treatment may be required for effect. 52 When the
tered orally three times daily for 1 week to 2 red filter s removed, the patient should immedi-
months. The positive results n children and adults ately continu constant direct occlusion to rein-
persist for several months after cessation of medi- force the new foveal fixation pattern, if t has
cation. Direct occlusion conducted concurrently been established.
does not seem to faciltate the positive effects, but
it extends the improved visual functioning of the Prism Therapy and Occlusion
ambiyopic eye for periods up to a year. 48- 49 Another method of treating intractable, steady, EF s
Reported side effects of the medication are consid- the use of inverse prism and direct occlusion, either
292 Chapter10
Perceived
f
e
FIGURE 10-7Inverse prism n case
of nasal eccentric fixation of the right
T eye, with the left eye being occluded.
PVD a. Image of the penlight falls on point
e. b. A base-in prism is placed before
the right eye to cause the image of the
(c) penlight to be projected to a point that
is nasal to point e. c. Right eye picks
up fixation with point e as the patient
wears the base-in prism for several
weeks. The principal visual direction
(PVD), however, remains at point e.
There is now a disruption between the
i, habitual eccentric eye position and the
1 straight-ahead perception for eye-hand
I, e f
coordination. d. The eye further
adducts so that the mage of the pen-
light falls on the fovea (f), as a result of
prolonged wearing of the reverse
prism and fast pointing exercises. The
principal visual direction is at the
fovea.
(a) (b)
54
opaque or graded. Pigassou and Toulouse recom- methods have not been successful and the patient
mended applying an inverse prism before the has either steady EF or unsteady EF n which the fix-
amblyopic eye while the nonamblyopic eye is ation pattern does not include the fovea.
totally occluded with an opaque patch. Also using Prism therapy s essentiaily passive therapy, but
55
inverse prism, Rubn recommended using graded, monocular fixation activities, such as eye-hand
direct occlusion with sufficient neutral-density fil- coordination exercises or Al transfer and fast point-
ters to reduce the VA of the nonamblyopic eye by at ing, can be added for the purpose of associating
least two lines below that of the amblyopic eye. the straight-ahead position with the true spatial
The hypothetical rationale behind using inverse location of the target (see Figure 10-7d). The exact
prism n this monocular technique is to shift the true location of the fixation target is verified by the
principal visual direction from the eccentric point tactual-kinesthetic sense when the patient touches
to the fovea. In the case of nasal EF of the right eye, the target with a finger or a pointer.
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 pri- Short-Term Occlusion
mary position. The patient has a new opportunity In the late 1970s, the ntroduction of the CAM (CAM-
to establish the oculocentric direction at the fovea, bridge) stimulator therapy for amblyopia generated
because the od directionalization pattern s dis- excitement, because its use often seemed to result in
57
rupted by the prism. The recommended amount of quick mprovement of VA. This rotating device con-
prism power slightly exceeds the amount of EF sisted of seven high-contrast, square-wave, spatial
A A
(e.g., 6 base-in for 5 steady nasal EF). In less frequency gratings presenting an acuity range from
prevalent cases of temporal EF, the prism (Fresnel 20/20 to 20/200. Each grating is viewed monocularly
or clip-over) is applied base-out. with the amblyopic eye and rotated at the rate of 1
Several other versions of prism therapy for EF revolution per minute in ascending order (.e., from
56
have been suggested by various authors, with and low to high spatial frequencies). The total training
without penalizaron, but there s little evidence time per session is only 7 minutes. Snellen VA was
supporting their efficacy over conventional, direct reported to increase approximately two lines on aver-
occlusion. For this reason, we suggest prism therapy age after only a few sessions. However, controlled
be tried only if standard patch i ng or penal ization studies that followed the initial positive clinical
Chapter10 293
case in which stable EF occurs, patching s tempo- ored pencils, the result s often quite stunning. Pre-
rarily switched to inverse rather than direct occlu- cisin and detail are desirable. The patient should
sion. Fixation training then is provided using foveal bring n all drawings and tracings for inspection by
tag techniques and pleoptic therapy (described the therapist. Progress in eye-hand coordination s
later). Fortunately, most patients progress well evident.
without the need for foveal tag techniques or for- Connect-the-dots books provide other excellent
mal pleoptics. eye-hand coordination challenges to the ambly-
opic patient. The task requires accurate fixation,
visual search, and tracking. Dot-to-dot games are
Fixation and Ocular Motility available in many toy stores, bookstores, and edu-
Activities (without Foveal Tag) cational supply stores.
The number of monocular fixation and motility
activities for the amblyopic eye that have therapeu- Throwing and Hitting Carnes (T10.2)
tic valus limited only by the clinician's imagina- To the delight of children and the chagrn of par-
tion. The following materials and activities represent ents, throwing and hitting games are particularly
techniques that we have found to be particularly suited for the development of accurate foveal fixa-
interesting and effective with patients. At all times tion and spatial localizaron. The nonamblyopic
during this phase of training, any significant refrac- eye is occluded during training activities. The
tive error should be optically corrected and the accuracy of the outcome is immediately apparent
patient should wear an occluder over the nonam- to all (i.e., good visual feedback). There s constant
blyopic eye. motivation to improve performance by adopting
compensating strategies. The reflexive eye-hand
Eye-Hand Coordination Techniques movements involved in the game are also thought
The following monocular techniques require a to promote foveal localizaron. Some of the more
high level of accurate eye-hand coordination. The popular activities include basketball, baseball bat-
patient's goal s to become equally skilled in the ting and catching, Ping-Pong, magnetic darts,
activities using each eye to guide performance. beanbag toss, tennis, badminton, and marbles.
Ideally, visual skills of the amblyopic eye should With proper precautions, amblyopic children and
eventually be improved to equal those of the dom- adults should be encouraged to particpate in these
inant eye. games as part of their direct occlusion program.
This eases psychological acceptance of occlusion.
Tracing and Drawing (T10.1) Several electronic fixation instruments are used in
Tracing and drawing activities are some of the easiest developmental and sports visin training (for
and most effective home techniques for improving example, Figure 10-8). In one mode, lights flash on
eye-hand coordination, visual tracking, and VA of the in a random pattern and the patient hits the appro-
amblyopic eye. Pictures from any source can be used priate spot or button to turn each light off. Speed
(e.g., comic books, newspapers, magazines). If the and accuracy are monitored by the instrument.
amblyopia is deep (marked), simple pictures with Because the activity develops reflexive eye-hand
bold Unes should be selected. If the amblyopia is coordination, t s ideally suited for training proper
shallow (mild), then fine lines and a lot of detail are localizaron with the amblyopic eye.
appropriate. Thin, translucent tracing paper is placed
over the picture, and the patient traces it as quickly as Video Game Tracking (T10.3)
possible using sharp, colored penis. The completed Video and computer games are now omnipresent,
tracing is compared with the original picture, at and they are conveniently available n many
which time corrections should be made. Speed and homes. Because of the addictive quality of some
accuracy are important goals. ' electronic games, many parents have to limit the
Another home activity involves drawing a figure amount of time their children spend on this activ-
(such as an outline of a hand) and making as many ity. Amblyopic children, however, should be
internal or externa! concentric copies of that figure encouraged to practice various shooting, chasing,
as possible. Each concentric figure should be and other eye-hand coordination games using only
drawn as cise to the last as can be resolved with the amblyopic eye, because the game score gives
the amblyopic eye. If the drawing is done with col- immediate feedback as to the player's skill level.
Chapter10 295
The patient should try to match his or her skill level suspended by a string from the ceiling. If an eye
using the amblyopic eye with that o the nonam- hook is used to suspend the ball and the string is
blyopic eye and record the daily high score for tethered to a side wall, the bal! can be easily raised
inspection by the visin therapist or doctor during and lowered as needed. The bat may be colored in
office visits. Requesting 30 minutes or 1 hour per various segments. Often four colors, symmetrically
day for these active visual tracking activities usu- arranged, are preferred on each end of the bat
ally is considered by the patient to be a privilege (e.g., the end segments are red, the next are green,
rather than a burden. Shippman 25 reported good and so forth). One task is for the patient to hold the
results with a clinical series of amblyopic children, stick with two hands and hit the ball with idntica!
ages 4-10 years, who used video games as a treat- segments on the left and right sides of the bat,
ment option. Of 19 patients who were unsuccess- while the nonamblyopic eye is occluded. The
ful using direct patching alone, 15 showed patient attempts to establish a regular pattern for at
substantial improvements n VA once home video least 20 hits. Using the end segments of the stick is,
games were introduced for an average training of course, the most difficult. Some therapists
period of 9 weeks. include a general balance requirement as the train-
Several prepackaged visin training computer ing progresses. The child is required to stand on
programs are commercially available (e.g., Com- one leg or on a balance board while hitting the
puterized Aided Vision Therapy by Vogel; Com- ball. Children usually enjoy these activities and are
puter Orthoptics by Cooper; see Appendix J). Such willing to train for relatively long periods.
programs have activities nvolving eye-hand coor- Visual tracking, with or without an Al tag, also is
dination and visual tracking, usually in a game for- very effective using a Marsden ball. Swinging the
mat. A doctor specializing in visin therapy should ball marked with letters in a fore-and-aft circular
find such systems useful n clinical practice. pattern provides an accommodative as well as a
pursuit tracking stimulus. The goal in this case is to
Swinging Ball Training (T10.4) keep the letters clear at al I times as the are of the
A practica! method of home training for improving excursin is increased. Simply swinging the ball n
smooth pursuits, accommodatl've facility, eye-hand the horizontal plae with the patient standing per-
coordinaron, and perceptual skills of directional- pendicular to the swing gives a periodic, predict-
ity is the use of a bat and a Marsden bal I (Figure able, smooth pursuit stimulus for the patient to
10-9). A rubber ball on which letters are drawn is follow. If the patient lies on the floor beneath the
296 Chapter 10
ball, a circular pursuit tracking pattern is demanded. opic eye sights along a line, makes accurate sac-
These smooth pursuit techniques are particularly cades, and follows it to its end. Initially, the patient
effective if an Al tag is used for visual feedback of may require a pointer stick to help keep his or her
tracking accuracy. eye on the line but, as speed and accuracy develop,
only visual tracking s desired. Besides recording
Tracking with Auditory Feedback (T10.5) the correct answers, the patient should also record
Various instruments can produce sounds indicat- the completion time for each task. We have discov-
ng the status of eye-hand coordination. The ered that some children enjoy making their own
Wayne Perceptuomotor Pen (see Appendix J), for line mazes. An example of a design of a 9-year-old
example, is a coordination device that gives audi- patient is shown in Figure 10-11. The child feels a
tory feedback when inaccurate manual tracking or sense of pride n the designs he or she has made. A
pointing occurs (Figure 10-10). With the nonam- key is made up, and the patient can administer the
blyopic eye patched, the patient attempts to trace test to siblings or friends who do not always fare
curved line figures. For dot targets, the patient per- well on some of the more elabrate patterns. This
forms fast pointing. Many training tasks stimulate sometimes provides a much-needed ego boost to
accurate fixation, pursuits, saccades, and eye-hand the amblyopic child who wears a patch. Groffman's
coordination. We have found T10.5 techniques to visual tracing patterns are also available on the
be most effective when each task is timed, so that Computer Orthoptics system for in-office reinforce-
the patient can work on both speed and accuracy. ment of this skill.
include Letter Tracking (Figure 10-12), Symbol workbooks, which can be highiy challenging for the
Tracking, and Word Tracking. For adults, Limercks ambiyopic patient. (Elaboration on the Ann Arbor
Word Tracking s entertaining. Some of these work- Tracking technique is provided in Chapter 19.)
books are printed in red ink, which is helpful n
breaking suppression and training visual tracking Resolution Techniques
with the ambiyopic eye under binocular conditions As is true in the nonambiyopic eye, the ambiyopic
(see the section Red Filter and Red Print [TI 0.21], eye can resolve and identify details best with
later in this chapter). Ann Arbor Publishers (see foveal fixation. 63 In the case of amblyopia, the
Appendix J) also distributes perceptual activity peak foveal acuity often is reduced, and oculomo-
298 Chapter10
HartCharts(T10.8)
Hart Charts (originally conceived by Dr. Walter Hart
of Tacoma, WA) often are used in the training of
accommodative facility, because the task involves
discriminating and identifying letters in sequence
from two charts, one at far and the other at near
(Figure 10-13). (Refer to Chapters 16-19 for further
discussion.) However, the task is also ideal for train-
ing saccadic eye movements and visual search with
amblyopic patients. Two identical charts are set up
in different locations in a room. The patient alter-
nately fixates the same letters in sequence on the
FIGURE 10-11Sample visual tracing exercise. Lines are first drawn charts as rapidly as possible. The therapist assigns an
by the patient and later followed visually with the amblyopic eye.
appropriate number of rows or columns to com-
plete in a set, based on patient observation. A single
tor and localization skills are deficient The patient set should take 1-2 minutes before a short rest is
can be taught to use the peak rea of the ambly- allowed. A sufficient number of sets is assigned to
opic eye for fixation by searching for and identify- fill at least a 10-minute time interval for this particu-
ing threshold letters or targets. These targets will be lar exercise. As the patient improves, the horizontal
recognized only if there is foveal fixation. Most fix- separation of the charts is increased. The patient
ation techniques described previously can add the should be reminded to use only eye movements,
resolution requirement by using the appropriate not head movements, for saccades. Realistically
that with occlusion and active participation n trainng technques discussed subsequently n this
amblyopia therapy, they will significantly improve secton. (Figure 10-14 shows the Bernell nstru-
their eye movement skills and VA. In this respect, ment and accessories.)
visin therapy is much like physical therapy.
Patient cooperation and honesty n reporting Preparation for Afterimage
observations are critical to trie success of these
techniques. In our experience, most children who
Transfer Training
are at least 8 years od can usually cooperate fully An inexpensive electronc camera flash attachment
with these techniques. Some precocious 5-year- can be easily modfied for use n binocular assess-
olds can also particpate adequately. ment and training. For clinical purposes, a good Al is
a thin streak with a small gap in the middle. The face
of the flasher s masked with opaque tape n the man-
Preparation for Haidinger ner illustrated n Figure 5-40. The modified flasher s
Brush Training held vertical ly approximately 40 cm from the patient,
Initially, the amblyopic patient s allowed to view whose amblyopic eye s occluded. The patient fixates
the Haidinger brush (HB) with the nonamblyopic, the center of the gap in the masked une with the non-
dominant eye for the purpose of identification. amblyopic eye as the therapist triggers the flash. The
(See Chapter 5 for a description of HB testing.) The occluder then s switched from the amblyopic to the
density of the cobalt filter s adjusted to maximize nonamblyopic eye so that the patient can see a trans-
the HB's vivid perception; filters can be added to ferred projection of the Al with the amblyopic eye.
the screen of the Macular Integrity Tester-Trainer The Al can best be perceived and maintained if a
(MITT). The patient wears corrected ametropia light source directed to the nonamblyopic eye (from
with most plus (CAMP) lenses (if any ametropia) the side and behind the occluder) is constantly flash-
and sits approximately 40 cm from the MITT. With ing on and off; blinking of the nonamblyopic eye is
the dominant eye occluded, the patient fixates a another way to help maintain the Al. The Al usually
suprathreshold letter with the amblyopic eye and persists for approximately 3 minutes, after which time
locates the position of the HB on the screen. The the technique s repeated.
therapist asks the patient to use a pointer stick to In cases of strabismus with ARC, it is important
indcate the exact positon of the HB. The patient to check whether the Al has transferred to the
and therapst are now ready to use any or al I of the fovea of the amblyopic eye rather than to an
302 Chapter10
Haidinger Brush
. Haidinger brush If a patient with EF has difficulty moving the
amblyopic eye to align the HB with a suprathresh-
old target, the therapist can use a pointer stick to
guide fixation. The patient fixates the tip of the
pointer stick with the EF point. The therapist moves
the pointer as the patient tracks t to a position
where the HB s centered on the target. On
FIGURE 10-15Slide of the Macular Integrity Tester-Trainer for use with repeated triis, the pointer is moved faster to
the Haidinger brush for development of steady and central fixation. achieve centricity of foveal fixation. Eventually, the
patient should be able to make the fixation move-
ment unguided. At this stage, the patient does not
extrafoveal eccentric point. The alignment of the
necessarily "feel" as if he or she is looking directly
transferred Al for the amblyopic eye can be veri-
at the target when the foveal tag is aligned. The
fied by having the patient simltaneously lcate
patient may also find it difficult to hold the tag on
the position of the HB on the MITT. If the gap of
the target for any length of time.
the Al s coincident with the center of the HB, the
transfer has been successful. However, f misalign- Afterimage
ment of the two exists, the Al has transferred incor-
With the dominant eye occluded, the patient is
rectly. Wick 71 recommended that the patient
nstructed to move the transferred Al directly to a
physically hold the amblyopic eye closed with his
suprathreshold letter or real object at any distance
or her fingers while applying the Al to the domi-
in the room. If difficulty is encountered, a guide
nant eye. He found that the Al is more likely to
object is held by the therapist and moved to the
transfer to the fovea of the amblyopic eye if this is
proper location to align the Al with the object of
done, although it does not happen in every case.
regard. The patient fixates the guide object with the
The reason for correct transfer of the Al is unknown,
EF point. Speed and accuracy of aligning the tag
but we speculate that increased dissociation (less
with the target of regard is developed by repetition.
natural) between the two eyes, with fingers holding
With practice, the patient should be able to
the eye closed, may elicit the innate normal retina!
achieve alignment quickly without a guide object.
correspondence (NRC) localization. In cases of
strabismic amblyopia, it is prudent to check with
Steadiness of Fixation Training (T10.14)
HB testing to determine whether the Al has, in fact,
The goal of steadiness of fixation training is to
transferred correctly. Once the therapist is assured
develop steady central fixation. In most cases of
of correct Al transfer, training of fixation and motil-
amblyopia, with or without EF, the fixation pattern
ity with this tag can proceed.
s unsteady to some degree. Initially, there is little
control of unsteadiness but, using this technique,
Foveal Tag Training the patient can usual ly reduce the amplitude of
The following tagging techniques are hierarchi- unsteadiness in small steps. Visuoscopy can be
cally sequenced on the basis of our clinical experi- used as an independent test to monitor progress. A
ence. They can, however, be mixed during a clinical goal might be to improve the degree of
therapy session based on the needs and responses steadiness with the amblyopic eye to that achieved
of a particular patient. with the nonamblyopic eye. Most patients require
10 or more training sessions to accomplish this
Basic Central Fixation Training (T10.13) goal, but there is large individual variation.
The goal of basic central fixation training is to
establish the rudimentary ability to move the Haidinger Brush
foveal tag rapidly to a target of regard. Later, the The beginning slide is the one with five letters,
goal is for reflexive responses. Initially, a guide tar- each placed nside a circle (Figure 10-15). The
Chapter10 303
tprient places the HB on one letter and notes the letters (achieved by varying the distance) are pre-
jlitude of unsteadiness of fixation. The patient sented, and more targets are added to the routine.
closer or farther from the screen until the i of The goal is improved speed, as inaccuracies tend
unsteadiness falls mostly within the circle, then to reduce the completion time.
the patient maintains that distance for iining.
The patient then makes a mental effort to the Aftermage
HB within the circle for a 20-second jnt. The A number of objects or printed acuity charts (five,
patient counts aloud. When the center the HB initially) are placed about the room, separated by
moves outside the circle, the patient varying distances from one another and from the
counting. The count s started again as the nt patient. Young children respond best to small toys
attempts to achieve this intermedate goal 20 as targets, whereas older children and adults can
seconds of improved steadiness. When that is use Hart Charts. A specific letter on each chart
ii'eved, the patient moves farther back from the becomes the fixation target, so there is a visual
2n, establishes a new training distance, and search requirement in a complex field. When the
jins again. When the circle slide is mastered, an foveal tag s successfully placed on each target in
jity chart slide is substituted, and the perfor- sequence, the patient indicates this by saying
ice criterion becomes maintaining the HB on "now" or counts the number of targets successfully
riously sized letters. The final goal is to maintain fixated. The patient is timed on a sequence of pre-
fixation on threshold letters. dictable and unpredictable targets and, with
progress, longer sequences are added. If a desk
mage clock s available for home training, some patients
| Wth the Al transfer tag, the patient should note the prefer to count the number of targets sequentially
ipDsition of the Al gap with respect to the boundary fixated within an assigned time (e.g., 2 minutes).
o the fixation target. Real objects can be placed The clock can be one of the fixation targets. A clin-
faround the room at various distances; golf balls or ical goal is to maximize the number of fixations
jtnys often are convenient targets. The patient within a specified period using targets that are
; affiempts to hold the Al tag on each object for the almost threshold.
count of 20 seconds. As the training progresses, Another variation of this technique s to intro-
smaller objects and greater distances are used. The duce a saccadic stimulus by a prism placed before
goal is to maintain steady fixation on threshold let- the ambiyopic eye while the patient fixates a par-
Icrs or objects at al I distances. ticular target. The prism shifts the perceived mage
in the direction of the prism apex. The patient
Saccadic Movements with attempts to realign the Al on the target as quickly
Foveal Tag (T10.15) and accurately as possible. The prism amount and
fciaccurate saccades usually are found with ambly- base orientation are varied to introduce new stim-
opia. The foveal tag allows the patient to be aware ul. Again, the number of the patient's correct
of these saccadic errors so that corrective strategies responses is timed.
can be learned. The goal of saccadic movements
with a foveal tag is to build fast, accurate, single Foveal Localzation with
saccades from one threshold target to another. As a Fast Pointing (TO. 16)
tule, each timed set should take from 1 to 2 min- Cppers believed that the cause of EF was a shift of
utes of active effort and should be followed by a oculocentric direction to an extrafoveal point that
short rest period. occurred secondary to the development of ARC.60
Whether or not this dea s correct may be deter-
Haidinger Brush mined by further research. Nonetheless, successful
With the circle slide n place, the therapist notes treatment of EF requires a shift of the "straight-
the time it takes a patient to fixate all five targets ahead" locus back to where t belongs, the fovea.
sequentially. When the HB s successfully centered Remediation of oculocentric direction starts by
on each target n sequence, the patient indicates demonstrating to the patient the monocular aiming
this by saying "now." The therapist times the error. This demonstration can be accomplished by
patient on both predictable and unpredictable tar- means of eye-hand coordinaron feedback. The
get sequences. As training progresses, threshold goal is to establish central foveal spatial localiza-
304 Chapter10
tion in the amblyopic eye, at least under monocu- logic development of pursuits is not sufficiently
lar conditions. understood to permit us to describe how people
Because there are no significant differences inhibit saccades during pursuits. With visual experi-
between the HB and Al foveal tag techniques, a ence and training, however, the amblyopic eye can
generalized technique is described. The technique improve pursuit skills.
involves fast pointing and adjusting to the result.
The patient holds a pointer stick behind the head in Haidinger Brush
a spearlike throwing position. The patient looks at The therapist moves a pointer stick slowly across
the target and checks to see whether the foveal tag is the screen of the MITT as the patient attempts to
directly on the target and makes the appropriate keep the center of the brush on the tip of the stick.
adjustment. With no hesitation, the patient "hurls" The patient attempts to join the HB "propeller"
the pointer to the target without letting the pointer with the stick. The therapist adjusts the speed and
leave his or her hand. At the end of the thrust, no predictability of the pointer movement to the skill
correctional hand movements are allowed. Both level of the patient. The patient indicates inaccu-
patient and therapist can note the outcome, a hit or rate performance by simply saying "off." The thera-
a miss. Slow, studied movements are not accepted pist adjusts the target speed to a 75% success
during this technique; automatic hits are desired. level, or more, as judged by the time on target. The
The eccentrically fixating patient often misses n clinical goal is the mximum speed attainable at
a particular direction, and appropriate adjustment the 75% accurate tracking level, depending on the
must be made. The therapist emphasizes verbally choice of criterion by the therapist.
that the foveal tag position is the new straight-
ahead position. This provides motivation toward Afterimage
the goal. The patient adjusts the sighting on subse- Tracking with the Al is much more fun for the
quent attempts; compensation for the error is patient than is use of the HB, because the tech-
made, and the patient's hit rate increases. With nique can be performed in the open environment.
increasing proficiency, smaller targets are intro- Many moving targets are available, depending on
duced, and a remarkable effect occurs: The oculo- the inventiveness of the therapist and the patient.
centric direction shifts to the fovea. It is not known Some children at an aggressive stage prefer to track
whether the physiologic process is gradual or with an imaginary lser beam and others with a so-
instantaneous or what mechanism s responsible. It called magic wand. The Al remains in perception
can happen with occlusion alone, but visin train- for only approximately 3 minutes, which s the
ing facilitates the shift in monocular localizaron. time requirement for the tracking exercise. The
Fast pointing techniques hold the patient's inter- patient should indcate when inaccuracy occurs,
est. We find it effective if the amblyopic patient and the speed of target movement should be
advances to this level. The optimum technique is to adjusted to at least a 75% response time on target.
combine TI 0.15 with TI 0.16. For each fixation tar- The goal is to maximize the speed of accurate
get for which the foveal tag is aligned, the patient smooth pursuits. Target size is not an important
attempts fast pointing. The clinical goal is to variable. Rotators are particularly suited for this
increase the hit rate at a reflex level when using exercise (Figure 10-16; see also Figure 2-14). The
threshold letters or objects. patient attempts to maintain the Al tag on a partic-
ular detail of the Peg-Board target, starting at the
Pursuits with Foveal Tag (T10.17) center and working toward the periphery of rota-
Patients typically enjoy pursuit training, particularly tion. Later, the patient tries to place golf tees in the
with an Al tag, as it represents a competitive race: moving board. We particularly recommend the
Tne amblyopic eye must keep up with, but not beat, Peg-Board rotator because the task requires
the moving target. The latter target may be moved smooth pursuits, proper localization, and eye-
by the therapist's hand. Initially, many amblyopic hand coordination. The therapist should stop the
patients track a moving target with a series of sac- exercise temporarily when the patient's success
cades, similar to the pattern found during infancy. rate falls below 50%, either when placing or
The goal is smoothness and accuracy of tracking. removing the golf tees. The Al foveal tag can also
The foveal tag gives the visual feedback the patient be effectively used with many other pursuit targets,
needs to judge successful performance. The physio- such as a swinging Marsden ball.
Chapter10 305
tages associated with pleoptic therapy, however, annulus with a clear center s rotated into position
resulted in the current practice by most practition- over the fovea during the stimulation phase. The
ers of avoiding ts use altogether or reserving ple- foveal rea then is stimulated with 50 to 100 brief
optic techniques for intractable cases. flashes of a small spotlight. The patient is nstructed
Pleoptic techniques are time-intensive for both to perceive the light and look at it directly. After
doctor and patient. These techniques require spe- repeated series of bleaching and stimulating phases
cial instruments, expertise and, possibly, pupillary over several weeks, the patient s directly occluded
dilation at each session. Overall, pleoptics may be and practices fixation exercises using the amblyopic
no more effective than direct patching alone. eye. As the light sense develops, other approaches
However, patients who have not responded well to with special instruments are used.
direct occlusion frequently do make progress using Bangerter designed and introduced several other
pleoptic methods. techniques and instruments, involving eye-hand
coordination with auditory feedback (Acoustic
Localizer), the crowding phenomenon (Separator),
Bangerter's Method a spiral rotator (Centrophore), and the use of slide
In 1953 in Switzerland, Bangerter ntroduced the projection to build visual recognition of objects and
term pleoptics, which in its Greek derivation memory (Mnemoscope).3 These specific instruments
means "complete sight." 72 Bangerter had been are no longer manufactured, yet the principies are
using a bleaching and light-stimulating method to incorporated in various training techniques that are
treat amblyopia and EF during the 1940s.73 He currently available. (See the section Practica! Ple-
believed that EF was caused by a depression of optic Techniques.)
foveal acuity to a level below peripheral retina!
loci. He speculated that the decreased VA resulted
from a deep suppression scotoma in the strabismic Cppers' Method
or anisometropic eye: In an attempt to see more In 1956 in Cermany, Cppers took pleoptic methods
distinctly when the normal eye is occluded, the a step further. He believed that the priman/ reason for
amblyopic patient would select an eccentric point EF in an amblyopic eye was a shift of "straight-
or rea for fixation. However, subsequent research ahead" localization away from the fovea. The individ-
has not supported Bangerter's hypothesis on the ual fixates with an eccentric point (or rea) because
etiology of EF.63 Nonetheless, his therapeutic he or she has a sense of looking straight at the target
methods have produced some mportant results with that extrafoveal point. Cppers believed that the
and inspired the development of other active monocular shift in localization occurred secondarily
amblyopia therapies. The emphasis of his therapy to the development of ARC in strabismus cases. In
is to stimulate the development of the foveal light ARC, there is an eccentric point or rea in the strabis-
sense and VA. mic eye that corresponds in visual direction to the
Bangerter designed the Pleoptophor (also spelled fovea of the dominant eye. He believed that this
Pleoptophore), which can accurately stimulate the same point (or rea) also represented the straight-
fovea with light. The technique s ntended to ahead direction under monocular conditions (i.e.,
develop the suppressed light sense of a deeply oculocentric zero).62
amblyopic eye. The therapy consists of two phases, Cppers developed the Euthyscope by modify-
the bleachng phase and the stmulating phase. The ing an ophthalmoscope so that the clinician could
method requires dilation of the amblyopic eye, as bleach an eye while sparing the fovea. in this
do most pleoptic methods. During the bleaching respect, the technique is similar to Bangerter's
phase in the Pleoptophore, a macular "shield" is method on the Pleoptophor. Euthyscopes are not
placed over the fovea of the amblyopic eye so that currently being manufactured. However, a black
the eccentric point s bleached out with high-inten- spot can be painted on the center of a reticule of a
sity light while the fovea is spared. The clinician direct ophthalmoscope to convert t into a simu-
directly views the fovea's position and the macular lated Euthyscope. The amblyopic eye is dilated,
shield during the bleaching (dazzling) phase to and the nonamblyopic eye is occluded. The
ensure that this result is effectively achieved. Thus, peripheral retina, including the EF point, is daz-
the peripheral retina, including the eccenthc point, zled as the clinician directly monitors alignment of
is dazzled (.e., relatively desensitized). Next, an the foveal shield (black spot) on the fovea. After
ChapteMO 307
a.
c.
d.
dazzling, however, the patient monocularly views conventional occiusion and training. This clinical
the negative Al of the foveal shield n free space on guideline s supported by two excellent reviews of
a wall of the visin therapy room (Figure 10-17). the extensive literature regarding the efficacy of
The patient then is instructed to center the Al on pleoptic therapy. 7' 60 Overall, pleoptic therapy
acuity letters or small objects and to identify them. using indirect occiusion has not proven to be more
The eventual training goal is for the patient to cen- effective than direct occiusion. Garzia 7 correctly
ter the Al reflexively on small letters with the sense pointed out, however, that pleoptic therapy general
of "straight ahead" being associated with the ly was used with older patients and in cases of
fovea. Cppers also advocated eye-hand coordina- poorer acuity and larger amounts of EF. Further-
tion training, HB techniques, and other training more, Ciuffreda et al. 60 tabulated the results of
techniques to achieve this goal.3 eight large patient series n which pleoptic therapy
was successful in cases of amblyopia that did not
respond to standard occiusion therapy. Among
Efficacy of Pleoptics these studies, which included many adults, the
Availability of pleoptic instruments s limited. Gen- success rate (.e., 20/40 or better) varied from 38%
eral ly, pleoptics s not recommended by most to 100%, with a weighted average of 52% for
authorities unless a patient has a large magnitude patients with EF. These are mpressive results for
of EF (4A or more) and has not responded well to intractable amblyopia cases n all age groups and,
308 Chapter10
b. 40 mm
frosted
placed at the center of the lamp; and (3) a small, BINOCULAR THERAPY
red fixation spot also cut from tape (Figure 10-19). FOR AMBLYOPIA
The magnitude of EF s measured, and the distance
between point e and the fovea relative to a 40-cm Both antidiplopia mechanisms of ARC and suppres-
viewing distance is determined by calculation. sion must be considered when binocular training
Suppose the patient's right eye has 10A steady nasal techniques are ntroduced in amblyopia therapy.
EF. To protect the fovea during bleaching, the
patient necessarily must fixate 40 mm to the right
from the center of the black shield. The red fixation Anomalous Retinal
spot s placed n this position by direct measure- Correspondence Considerations
ment. The patient fixates the red spot with the In most cases of amblyopia marked by a constant
ambiyopic eye as steadily as possible for 30 sec- strabismus and ARC, t does not make good sense
onds during the bleaching phase. An mportant to switch from monocular amblyopia therapy to
point to remember s that this technique is of no binocular training. Frequently, the prognosis for
valu, and may actually hinder'therapy, unless the functional cure of constant strabismus and ARC s
center of the fovea is protected. The doctor must poor, and the excessive training effort may not be
monitor the amount of EF accurately and fre- worth the effort to achieve a possible higher qual-
quently (e.g., weekly) to ensure the effectiveness of ity of binocular visin. ARC, it must be remem-
this method. Continuing with direct occiusion, the bered, is a form of binocular visin in which there
patient perceives the negative Al of the shield, the is rudimentary peripheral fusin and, sometimes,
center of which represents the position of the fovea gross stereopsis but not central fusin. In such
in free space. The previously described Al training cases, t seems appropriate to settle for a cure or
techniques can be used for approximately 3 min- improvement of the strabismic amblyopia. The fol-
utes before the Al fades. If desired, a blinking back- low-up goal would be to maintain the improved
ground light helps to extend the perception of the acuity in the ambiyopic eye over time. Periodic
Al to approximately 5 minutes. Repeated cycles of occiusion of the nonambiyopic eye for a few hours
bleaching and training are conducted during each each month may be all that is necessary for this
in-office therapy session. Wick75'76 described a purpose. Better yet, f the patient can practice
similar home pleoptic method, but he used a altrnate fixation, using each eye for fixation at dif-
strobe flash to genrate the Al more quickly. ferent distances (e.g., with optical penalization),
310 Chapter 10
the good training results can usually be maintained gains are possible. In many cases, this change is
without patching. enough to achieve progress again.
In cases of comitant strabismus with unharmoni-
ous or paradoxical ARC or a large noncomitant
deviation (even with NRC), there is the possibility Antisuppression Techniques
that intensive binocular training can result n for Amblyopia Therapy
intractable diplopia. In these cases, even treating The most effective antisuppression method for a
the amblyopia alone s slightly risky for creating particular patient depends on the type of amblyo-
diplopia, because patching has an antisuppression pia (strabismic or anisometropic), VA level, and
effect. Care should be taken to monitor the patient depth and extent of suppression. More discussion
for diplopia as a result of patching; however, of specific antisuppression techniques can be
shortly after monocular amblyopia therapy, the found in Chapter 12. Here we will identify only a
patient usually begins to suppress again. In our few techniques that we have found to be particu-
opinin, it is inadvisable to initiate an intense bin- larly effective with ambiyopic patients.
ocular training program in certain cases, especially When suppression is deep and extensive, vigor-
n older children and adults, because of the risk of ous binocular light stimulation may be necessary
intractable diplopia. to establish the rudiments of binocular visin.
When NRC is present, as in cases of anisome- Strong light stimuli for breaking deep suppression
tropic or meridional amblyopia or intermittent stra- can be introduced by the use of (1) rapid altrnate
bismic amblyopia, binocular training is effective flashing (e.g., Alien Translid Binocular Interaction
and very helpful n both improving the amblyopia [TBI] method), (2) a red lens with vertical prism
and developing normal sensory and motor integra- method, and (3) flashing fusin targets n an
tion of the images. amblyoscope in which the illumination gradient
favors the ambiyopic eye (see Chapter 12). Most
patients, however, do not require these intensities
Suppression and Amblyopia of light stimulation. Standard instruments and
An ambiyopic eye generally has deep foveal sup- techniques can usually break suppression and
pression as a fundamental characteristic of the build fusiona! vergence ranges simultaneously.
condition. Suppression is believed to play a role n We often use Wheatstone mirror stereoscopes
the etiology of amblyopia. Therefore, an important (e.g., Bernell Mirror Stereoscope), Brewster stereo-
therapeutic goal in cases n which binocular visin scopes (e.g., Keystone Telebinocular), Trana-
is expected to be restored, particularly anisome- glyphs, Brock string and beads, Minivectograms,
tropic amblyopia, is the elimination of Suppression and red-green or polarized televisin trainers. At
through occlusion and visin training techniques. some point n fusin training of an ambiyopic
One commonly seen benefit of antisuppression patient with the potential for normal fusin, prac-
therapy is an mprovement in monocular VA of the tically all antisuppression methods are applicable
ambiyopic eye. For this reason, many clinicians and can be used for variety to build motivation.
prefer to introduce antisuppression and sensory For ambiyopic patients, we recommend using the
and motor fusin techniques when the VA of the three antisuppression techniques described next,
ambiyopic eye improves to within a practica! bin- because they improve necessary tracking and res-
ocular range20/80 (6/24) or better. Other clini- olution skills besides breaking suppression. These
cians wait until 20/40 (6/12) acuity s achieved techniques are particularly appropriate for ani-
before introducing these techniques. There is no sometropic amblyopes in whom there is normal
consensus in the literature as to the optimum time fusin potential.
at which to emphasize antisuppression techniques,
so the choice is properly left to the clinician's dis- Red Filter and Red Print (T10.21)
cretion in a particular case. If progress stalls for 4 Many of the Ann Arbor Tracking Program work-
weeks or more in a remediation program of occlu- books are printed in red ink, which makes them
sion and monocular training and the ambiyopic appropriate for antisuppression training. A red filter
acuity s 20/100 (6/30) or better, we suggest or lens is placed in front of the nonamblyopic eye.
switching the emphasis of the training to antisup- (Red-green filter glasses also work well.) The con-
pression techniques to determine whether further tours of the workbook itself provide the binocula
312
times a certain designated word appears in a news- so. Sometimes the fixation pattern becomes more
paper article. central, without a corresponding mprovement n
Recommendations for Binocular acuity until a few weeks later. If there s no
Training mprovement in the fixation pattern orVA during a
In cases of NRC, for which gross suppression and 1-month period, we change the approach and
monocular tracking under binocular conditions has introduce new techniques. For example, f a pla-
been improved, various sensory and motor fusin teau occurs with direct patching and monocular
techniques can be introduced to establish optimum viewing games n a case of anisometropic amblyo-
binocular skills. All inaccuracies in pursuits, sac- pia, one might introduce binocular techniques
cades, and accommodation need not be eliminated even f the amblyopic acuity has not improved to
before further binocular training is nitiated. Ideally, the 20/80 (6/24) to 20/40 (6/12) levis, as previ-
the patient should have achieved at least 20/40 (6/12) ously suggested. If the patient has a stabilized EF
full-chart acuity, no gross suppression, some degree point, however, indirect patching and in-office ple-
of stereopsis, and basic monocular tracking skills optics may be an appropriate change. Therapy is
before binocular visin training proceeds further. continued as long as some mprovement occurs
Once these goals have been achieved, the emphasis during a 1-month period. When there s no signifi-
of the training program changes to new goals, cant improvement for 2 months, despite the
depending on the case: (1) establishing and reinforc- patient's best efforts, the mximum visual potential
ing NRC if there is ARC and treatment is deemed of the amblyopic eye has probably been reached.
advisable (Chapter 11); (2) eliminating foveal sup- The remaining dficit can be considered to be
pression (Chapter 12) and building fusional vergence amblyopia of arrested development, and further
ranges and reflex responses (Chapters 13, 14, and improvement is unlikely.
16); or (3) f strabismus remains, reducing the angle of In ali cases of amblyopia therapy, the final step is
deviation by surgical or optical means. Regardless of to prevent its recurrence. The fu 11 optical correction
which direction subsequent therapy takes, the patient of any significant refractive error will have to be worn
should be given maintenance home training tech- indefinitely, at least for young children. Patients need
niques and periodic monitoring to prevent regression to be aware of and accept this fact from the outset.
of the mproved VA of the amblyopic eye. An example of cure and regression s that of Eric, a
Progress in Amblyopia Therapy 10-year-old boy seen by Dr. David Kirschen of the
Southern California College of Optometry. The
We agree with Caloroso and Rouse77 that a short
patient had anisometropia with ntermittent exotro-
diagnostic reassessment during visin therapy should
pia, but no treatment had been given until age 8
be conducted at least every 4 weeks. Initially, we
years, at which time patching was tried. Dr. Kirschen
schedule patients for office visits on a weekly basis.
first saw Eric at age 10 and prescribed spectacles,
The ideal acuity test to monitor progress n amblyo-
patching, and monocular training activities. The acu-
pia therapy is the psychometric S-chart but, f this test
ity of the right eye was 20/120 and the left eye was
is not done, then a variety of Snellen charts should be
20/20. The acuity of the right eye mproved to 20/20
used to prevent memorization. Full-chart, single-line,
in 11 weeks as a result of constant, altrnate patching
and single-letter acuity thresholds should all be
(the amblyopic eye patched at school, the nonambly-
assessed periodically. The fixation pattern usually is
opic eye patched the remainder of the time) along
monitored by visuoscopy. The refractive status must
with monocular training techniques. (Figure 10-21
be rechecked periodically, as the ametropic correc-
shows VA of the right eye before and after the visin
tion sometimes requires refinement during the course
therapy.) The interesting point to be made in this case
of therapy.
is that visin therapy is effective n older children, but
Within week 1 or 2 of patching and visin train-
amblyopia can return unless there s maintenance
ing, the acuity of the amblyopic eye typically
therapy (including wearingthe lenses). Eric, however,
shows some ncrease. Further mprovements may
decided not to wear his glasses and had approxi-
occur in steps, and there may be an extended pla-
mately 20/100 VA on follow-up examination 1
teau at a particular acuity level. Changes n acuity
month later. He was advised to resume wearing the
and improvement in the patient's fixation pattern
spectacles and to perform monocular training tech-
often are directly related, but this s not necessarily
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.
iques at home, as was done previously. Follow-up optical penalizaron with spectacles or contact
examination 2 weeks later found Eric to have 20/20 lenses on a regular basis, as described previously.
acuity in each eye. The doctor must be convinced, however, that the
In such cases, we often assign an antisuppression patient does, in fact, switch fixation in response to
activity for 30 minutes once weekly, such as a reading optical blur. In this way, one eye would be used for
bar or televisin trainer. If the patient notes suppres- fixation at far and the other for nearpoint viewing,
sion returning or VA regressing, an office visit is indi- thus ensuring the visual integrity of each.
cated so that we can prescribe an appropriate After the patient is dismissed from a completed
rehabilitation schedule and techniques. In our expe- visin therapy program for amblyopia, we prefer to
rience, the reinforcement schedule of 30 minutes schedule progress visits for 3 and 6 months and
once weekly is adequate in most cases, but some then, if all goes well, on a regular yearly basis.
patients do require a more frequent and intensive
eye requues
fixation. The patient might simply patch the dom't-
nant eye for 30 minutes once weekly while read- Abstract
ing, watching televisin, or engaging in other A 34-year-old woman presented with a hype
visual activities. Another approach would be to use anisometropic amblyopic eye that was
314 Chapter10
blind with best lens correction.78 There was EF, Altrnate at 20 cm: orthophoria with
suppression, and no measurable stereopsis. An occasional eso flick of left eye Stereopsis (none,
occlusion and visin training program of 4 months' Stereo Fly test), suppression OS Keratometry:
duration resulted in central, steady fixation, 20/40 OD: 44.50 180/45.00 @ 90
VA, and almost normal stereopsis. OS: 44.50 @ 180/45.50 @ 90
Retinoscopy (dry):
Case History OD: +0.75 DS (diopters sphere)
Mrs. Z, a 34-year-old housewife, presented with OS: +4.00 DS -0.50 axis 180
the report of a lazy left eye originating in early Retinoscopy (1% cyclopentolate):
childhood. She had no other visual problems or OD:+1.00DS
symptoms. As a Venezuelan national, Mrs. Z fol- OS: +4.25 DS
lowed her husband to the United States, where he Subjective (dry):
was completing a doctoral program. She had not OD: +0.75 DS, 20/20
previously received any treatment for her eye con- OS: +4.00 DS, 20/200
dition. In Venezuela during elementary school, she Phorometry: suppression OS, no data obtained
had been told that she had amblyopia, which was far or near Amplitude of accommodation:
an incurable condition at her age, but she now OD:7D
wanted a second opinin about that poor progno- OS: poor response
sis. There was a family history of hyperopia on her Accommodative facility:
mother's side but, to her knowledge, no member Normal OD
had strabismus or amblyopia. She felt in excellent Poor response OS
physical health, which was confirmed by a medi- Visuoscopy:
cal examination conducted 6 months previously. OD: steady central fixation
Her schedule allowed considerable free time, OS: 4A unsteady nasal and 1A superior fixa-
which she enjoyed. She had the time, resources, tion with +2A unsteadiness
and commitment to pursue amblyopia therapy. Oculocentric direction associated with
eccentric point OS
Clinical Data Haidinger brush: OD, steady central fixation;
VA at 6 m without therapy Oculus dexter (OD): OS, no brush seen
20/20 Snellen (6/6) Oculus sinister (OS): 20/400 Fields: full by tangent screen OD, OS full (used
(6/120) VA at 40 cm without therapy OD: 20/20 tape to indcate center of the field OS) Amsler
reduced Snellen OS: 20/100 reduced Snellen grid: OD, normal; OS, indistinct Color visin:
Externa! examination: adnexa and pupillary (Farnsworth panel D-15) normal OD and OS
reflexes normal Tonometry: OD, 15 mm Hg; OS, 14 mm Hg
Internal examination: normal oculus uniter (OU)
Extraocular movements (gross inspection) OD: Impressions and Diagnosis
steady fixation OS: slightly unsteady fixation No Mrs. Z can be described as having hyperopic, ani-
restrictions of monocular movements, but sometropic, deep amblyopia and nasal, unsteady
poor pursuits and saccades OS No strabismus EF of the left eye. There does not appear to be a
seen in nine fields of gaze (Hirschberg) strabismus, although it is possible that she has a
Nearpoint of convergence (NPC): 12-cm break, small microtropia. There is deep suppression of the
17-cm recovery left eye, and no stereopsis was elicited. Ophthal-
Cover test: Unilateral at 6 m: occasional eso moscopy, fields, tonometry, and color visin were
flick of left eye all within normal limits, so the eyes appeared
Altrnate at 6 m: orthophoria with healthy. The visin loss of the left eye is probably
occasional eso flick of left eye not due to an organic cause. She apparently had
Unilateral at 40 cm: occasional substantial uncorrected hyperopic anisometropia
eso flick of left eye during early childhood that resulted in a lack of
development of high-frequency resolution chan-
Chapter10 315
neis and poor fixation reflexes for that eye. The EF contact lenses were discussed, but she felt more
s larger than s found in many anisometropic comfortable with wearing glasses. Her spectacle
patients, but the amount does not totally account correction is also consistent with Knapp's law to
for the acuity reduction. Using the criterion of reduce potential aniseikonia, because the ani-
MAR = EF A + 1, the acuity reduction predicted sometropia is axial rather than refractive.
from 4A of EF would be approximately 20/100. The An Elastoplast occluder was worn on the right
Worth-Chavasse model of amblyopia would sug- eye under the glasses during all waking hours
gest that this patient would have acuity loss both except when Mrs. Z required good VA, as when
from lack of development and active suppression, driving or reading. She removed the occluder at
but the proportion of each s unknown. these times but continued to wear her glasses, so
The prognosis for a complete functional cure of there was some Mmited binocular stimulation.
the amblyopia was guarded due to the large The overall sequential training goals were (1) to
amount of unsteady EF that does not reach the establish steady central fixation and foveal local-
fovea, the low presenting acuity, the unknown ization OS; (2) to build accurate accommodative,
onset of anisometropia, and the late age of treat- pursuit, and saccadic eye movements OS; (3) to
ment. The age of treatment onset s not the most improve visual acuity n the amblyopic eye to the
important factor in establishing the prognosis, but mximum level possible; and (4) to break suppres-
t s a consideraron: Generally, the earlier the sion, develop stereopsis, and enhance sensory and
treatment, the faster and, to some degree, the bet- motor fusin.
ter the results.
The patient explained that having an essentially Monocular Fixation Training
blind eye had always disturbed her and that she Two or three techniques were given for home train-
hoped that she could recover some visin. There ing each day. Although 30 minutes of training was
had never been any attempt at therapy in her case the mnimum expectation, we recommended that
and, if progress were possible, some improvement each exercise be performed at a different time dur-
in acuity would be evident within a few weeks. ing the day. One technique usually was changed at
There would be little risk or inconvenience to the each weekly office visit for the sake of variety as
patient in the attempt. A therapy program was rec- well as for therapeutic reasons. The following tech-
ommended that ncluded constant patching (ini- niques were assigned:
tially) and a course of training, 30 minutes per day,
lasting approximately 3-6 months, depending on 1. Al transfer fixation training: The location of
the results. Mrs. Z enthusiastically accepted these the left eye's fovea was tagged with a transferred
conditions of treatment. Al, and various types of fixation activities were
Many clinicians recommend part-time, not full- assigned. A circuit breaker was placed n an
time, total direct patching in cases of anisome- incandescent lamp to provide a flashing back-
tropic amblyopia so binocularity s preserved. ground light. This helped to maintain the trans-
Because the corrected acuity was so reduced in ferred Al in perception for 3-5 minutes before the
this case and we wanted to learn quickiy whether Al had to be renewed. After the Al was generated,
any improvement was possible, we chose to the nonamblyopic eye was occluded with a tie-on
attempt almost constant, total, direct occlusion. patch. The following techniques were introduced
There seemed to be only minimal binocularity in the order Usted:
with full optical correction initially. Another a. Steadiness of fixation: Using only the tagged
approach would be constant inverse occlusion ini- amblyopic eye, Mrs. Z was instructed to place
tially for several weeks and then inverse patching and steadily hold the Al on a large target (e.g.,
supplemented by pleoptic therapy, but we keptthis book) for a certain amount of time (e.g., 30 sec-
option n reserve for reasons of expense and onds). She initially found this difficult to do
convenience. because the Al kept moving off to her left but,
with practice, she learned to hold the Al on the
Vision Training Plan target for ncreasing intervals. Smaller and more
Mrs. Z decided to attempt therapy. The subjective demanding targets were then ntroduced (e.g., a
refraction lenses were prescribed in the form of small clock, circles of various sizes, figurines,
spectacles. The advantages and disadvantages of thimbles).
316 Chapter10
recordad the vergence setting of the targets and her fixation skills. The S-chart acuity measured 20/120
best time each day. If suppression occurred, she consistently, and the EF appeared to have reduced
was to break it by blinking before continuing the to 3A nasal unsteady combined with 1 A inferior.
exercise. She increased her step vergences to 10A Mrs. Z subjectively noted the improvement in
base-in and base-out using this technique. visin and the improved control of her fixation pat-
3. Cross convergencestring and beads, pend tern. She found that direct patching was not a
push-ups, jump vergences: For example, a push-up major inconvenience when she was at home, but
technique was used with the string and beads to she removed it for driving, shopping, and other
build the smoothness of convergence training and activities requiring precise visin. She estimated
the NPC. Mrs. Z held one end of the string to her that she wore the patch 10-12 hours per day. Each
nose and tied the other end to an object (e.g., door- week she was tested for muscle balance (far and
knob). She moved a bead slowly and smoothly and near), and no decompensation was noted. Gross
tracked it from arm's length to her NPC while hold- Stereopsis of 3,000 seconds of are was found on
ng the percept of the strings crossing at the bead. If the Stereo Fly. The basic thrust of therapy (the
a physiologic diplopic clue of one string disap - aggressive direct occlusion and monocular fixation
peared, she stopped to blink or jiggle the bead to training) was continued.
renew the suppressed image before continuing. She After 2 months of therapy, 20/80 VA was consis-
would work on this for 2 minutes at a time, then rest tently found, and the EF measured 2A nasal, with the
her eyes a short time before continuing. Usually unsteadiness excursin including the fovea. Mrs. Z
four sets of 2 minutes each were completed. The faithfully complied with the patching and active
best NPC each day, the number of sets completed, therapy program and was gratified by the improve-
and the number of times suppression occurred were ment. Stereopsis of 400 seconds of are was found
recorded on the home training recording sheet. on the Stereo Fly test. The thrust of the therapy was
4. Accommodationaccommodative tracking, changed to building binocular visinintensive
binocular flippers, jump focus: For example, when antisuppression activities, fusional vergence, Stere-
visual acuity had improved to almost 20/40, Mrs. Z opsis discrimination tasks, and fixation exercises
was asked to read a magazine for 10 minutes using while suppression clues were monitored. Mrs. Z
a polarized reading bar wh'le she tromboned the welcomed the changes, as several new nstruments
reading material from arm's length to her nearpoint and techniques added variety to her home training.
of accommodation. The goal was to keep the print Direct patching was reduced to 6 hours per day to
clear at all times over her range of accommodation allow for more binocular stimulation.
without suppression, thus building smooth and There was slow progress, with a few plateau peri-
accurate accommodation. ods over the next 2 months of training. The acuity
5. StereopsisVectograms, stereograms: For ncreased to 20/40 by Snellen (full chart and line
example, Stereopsis awareness was emphasized acuity) and by S-chart. Central, steady fixation of the
using Vectogram 5, the Spirangle, with clues for left eye was achieved and appeared similar to that
each of the letters on the spiral. The instructions of the right eye by visuoscopy. A suppression-free
were first to move her eyes around the spiral rapidly range of fusional vergence became normal (see
to maximize the overall depth percept, then to dentify Chapter 2). Stereopsis slowly ncreased and stabi-
the stereo relief precisely in each particular letter. Ste- lized at 70 seconds of are. After 4 months of visin
reo awareness was trained at various vergence therapy, relevant data measured as follows:
demands to improve her discrimination skills.
Additional monocular fixation, saccadic, and pur- VA at 6 m without therapy
suit exercises included Ann Arbor tracking, Groffman OD: 20/20
tracing, dot-to-dot patterns, and threshold reading. OS: 20/40
Mrs. Z maintained excellent compliance throughout VA at 40 cm without therapy
the visin therapy program and often exceeded the OD: 0.4 M (20/20 reduced Snellen)
minimum training time expected each day. OS: 0.6 M (20/30 reduced Snellen)
Ocular motility:
Summary of Results Steady fixation monocularly and binocularly
After 3 weeks of direct patching and training, Mrs. Accurate pursuits and saccades
Z realized substantial improvement in acuity and No strabismus seen in nine fields of gaze
318 Chapter10
reader was performed to check on nearpoint sup- 8. Dorey SE, Adams GG, Lee JP, Sloper JJ. Intensiva occlu
pression. For home training, patching was discon- sion for amblyopia. BrJ Ophthalmol. 2001;85:310-313.
tinuad, but monocular eye-hand coordinaron 9. Saulles H. Treatment of refractive amblyopia in adults. J
Am Optom Assoc. 1987;58:959-960.
activities were performed. Vergence training and 10. Schoenleber DB, Crouch ER. Bilateral hypermetropic
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Lifesaver cards, the E series of Biopter cards, and 75-77.
cheiroscopic tracings. 1 1 . Kutschke PJ, Scott WE, Keech RV. Anisometropia amblyo-
pia. Ophthalmology. 1991;98:258-263.
12. Flynn JT, Woodruff G, Thompson JR, et al. The therapy of
Final Results
amblyopia: an analysis comparing the results of amblyo
At the twenty-fifth office visit, the patient's visual pia therapy utilizing two pooled data sets. Trans Am Oph
status was as follows: thalmol Soc. 1999;97:373-390.
13. Birnbaum MH, Koslowe K, Sanet R. Success n amblyopia
Best corrected VA at 6 m: OD 20/20; OS 20/25' 1 therapy as a function of age: a literatura survey. Am J
(Snellen); 20/30 (S-chart) Optom Physiol Opt. 1977;54:269-275.
Cover test: small eso flick (eso microtropia) at 6 m; 14. Hiscox F, Strong N, Thompson JR, et al. Occlusion for
amblyopia: a comprehensive survey of outcome. Eye.
2A esophoria at 40 cm
1992;6:300-304.
Central suppression of the left eye at far, consistent 15. Wick B, Wingard M, Cotter S, Scheiman M. Anisome-
with the microtropia, but normal fusin at near tropic amblyopia: is the patient ever too od to treat?
with 30 seconds of are of stereopsis and nor- Optom Vis Sci. 1 992;69:866-878.
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therapy initiated after age 7 years: compliance curves.
Accommodative facility: 14 yeles/minute OD,
Arch Ophthalmol. 2000;1 1 8:1 535-1 541 .
10 cy el es/mi ute OS, and 9 cycles/minute 17. Wilson ME. Adult amblyopia reversed by contralateral
binocularly cataract formation. BrJ Ophthalmol. 1992;29:100-102.
18. El Mallah MK, Chakravarthy U, Hart PM. Amblyopia: is
These findings were stable on 3- and 6-month visin loss permanent? BrJ Ophthalmol. 2000;84:952-956.
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Although there was a small amount of residual amblyopia n the age group 2 years and above: a prospec-
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20. Kageyama CJ, Loomis SA. Central fixation amblyopia: a
improvement of visual acuity and development of
case report. Optom Monthly. 1980;71 -.333-336.
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1986;6:21 3-220.
23. Ludlam WM. Orthoptic treatment of Strabismus: a study
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33. Gauthier CA, Molden BA, GrantT, Chong MS. Interest of 55. Rubn W. Reverse prism and calibrated occiusion in the
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chapter n / Anomalous Correspondence Therapy
Before deciding how to treat anomalous retina! binocular visin specialist. Many of the most effec-
correspondence (ARC), one should seriously con- tive techniques require the use of a major amblyo-
sider whether to treat the condition. The functional scope or other special instruments not ordinarily
prognosis for constant strabismus associated with found in a primary care practice. Most techniques
ARC generally is not good (as reviewed in Chapter demand much concentration and effort by both
6). It ranges from poor to fair depending on the doctor and patient, which also transales into time
type of strabismus and associated conditions. In and money. In some cases, patients experience
some cases, there s also a chance of causing severe eyestrain during therapy, and prolonged
intractable diplopia. double visin may be the sol outcome. The bene-
fits of normal binocular visin to the patient must
be weighed against all these and other negative
THERAPY PRECAUTIONS factors. Patients or parents must be aware of the
ARC therapy generally is not regarded as a primary costs and potential dangers before undertaking
care responsibility and often requires referral to a specific therapy for ARC. The doctor and patient
324 Chapter 11
(or parents) should discuss all relevant factors remote. Vision training probably will result in failure
before attempting to change ARC to normal retinal after a major investment of the patient's time, energy,
correspondence (NRC). and money. Horror fusionis, however, needs to be
Intractable diplopia often is associated with unhar- distinguished from several other conditions with
monious ARC (UNHARC) secondary to strabismus which it is easily confused. The differential diagnosis
surgery. However, most strabismic patients with ARC, includes deep central suppression, aniseikonia, and
even postsurgical cases, have harmonious ARC lack of fusin due to head trauma.3 Suppression can
(HARC), in which the subjective angle is zero. HARC usually be treated (see Chapter 10), and aniseikonia
is a rudimentary form of peripheral binocular visin can often be managed with iseikonic lens corrections
for a strabismic patient that results in single visin, (see Chapter 16).
some form of peripheral stereopsis awareness and,
often, some vergence eye movements that tend to
keep the angle of deviation relatively stable. Postop-
SENSORY AND MOTOR
eratively, particularly after late surgery for strabismus
THERAPY APPROACHES
in cases of early onset, the patient may not properly
readapt the ARC completely to the new angle of Therapy approaches usually are based on either the
deviation (i.e., angle A does not equal angle H). This sensory adaptation theory or the motor theory of ARC
meets the definition of UNHARC. Sometimes the gnesis. The sensory adaptation theory4'5 maintains
UNHARC is of a paradoxical type (paradoxical ARC that ARC develops as a secondary adaptation to
type one or two), which presents significant compli- early-onset strabismus when visual directionalization
cations to treatment. (See Chapter 5 for descriptions is plstic, as with many other visual functions. ARC
of these types of ARC.) Postoperative diplopia may localization is superimposed slowly on the innate,
result. Fortunately, in many cases, suppression pre- infantile NRC localization system and becomes
vents diplopia, although the correspondence remains embedded with reinforcement as the child lives with
unharmonious. Most of the training techniques used a constant strabismus. The rehabilitation approach
in ARC therapy are effective in breaking suppression. consistent with this theory suggests that ARC needs to
However, if NRC cannot be established, the patient be inhibited and NRC localization stimulated and
may have diplopia. reinforced. Early intervention is desired for a success-
The cautious clinician should admit into visin ful outcome, the earlier the better. Full-time occlu-
therapy only those ARC patients who exhibit sion often is prescribed for strabismic patients, even
HARC in the normal environment. The Bagolini in cases in which amblyopia is not present. Patching
test is particularly useful for this clinical distinc- prevens ARC from becoming embedded. Overcor-
tion. Patients with UNHARC in the open environ- recting prisms or other optical intervention may be
ment, particularly adults, present an unacceptable prescribed to disrupt ARC adaptation. Many special-
risk for treatment, n our opinin. Children, fortu- ized training techniques have been designed specifi-
nately, usually can learn to suppress to prevent cally to bring out the latent NRC system in an
diplopia when ARC therapy is unsuccessful. instrument environment, and later on, in open space.
Horror fusionis is another contraindication for The motor theory6-8 proposes that ARC occurs
ARC therapy. Horror fusionis is the inability to obtain simultaneously with the strabismus due to a neural
binocular superimposition even at the subjective dysfunction of the vergence system. Kerr9 suggested
angle with haploscopically presented targets. On an that the neural dysfunction is in the disparity detec-
amblyoscope, as the targets approach superimposi- tion system. When the strabismic deviation occurs,
tion, they seem to slide or jump past each other with- the change in motor innervation is registered
out apparent fusin or suppression.1 In cases of within a perceptual neural network controlling
strabismus with ARC, this central fusin dficit may spatial localization. This theory regards ARC as
be due to the notch in the horopter.2 In these cases, an all-or-none phenomenon rather than as an
horror fusionis is a common observation using fovea- entity of various depths, as proposed by the sen-
sized targets on an amblyoscope, but fusin can sory adaptation theory. The common finding of
sometimes be achieved using large, second-degree covariation in cases of intermittent exotropia and
targets. If horror fusionis is evident using both central some cases of intermittent esotropa provides evi-
and peripheral targets, ARC therapy is contraindi- dence for the motor theory. Vision training is
cated. The chance of achieving a functional cure is directed toward producing appropriate vergence
Chapter11 325
eye movements to straighten the eyes, thus stimu- mus, the doctor should be cautious in prescribing
lating covariation whereby ARC changes to NRC. occlusion, because so-called occlusion strabismus
(See Chapter 5 for a more detailed discussion of may result. This principie s particularly true in
these theories.) cases of heterophoria of high magnitude that may
We believe that both the sensory and motor the- decompensate and become strabismic f dissocia-
ories are, n part, correct. The nature of ARC is not tion (i.e., occlusion of an eye) contines over a
well understood at this time. In a particular patient, long period. When there is constant strabismus,
one or both mechanisms may be factors in the eti- constant occlusion is appropriate, provided there
ology of ARC and strabismus. We will, therefore, is alternation of occlusion appropriate for the age
discuss rehabilitation regimens based on both of the patient (to prevent occlusion amblyopia).
these approaches and suggest when one may be Often, however, the chief probiem is not the risk of
more clinically appropriate than the other. undesirable sequelae but the difficulty of ensuring
Before ARC therapy begins, amblyopia, if present, that the patient cooperates with wearing the patch
should be treated (see Chapter 10). Even though on a full-time basis.
treatment is hampered by the patient's lack of 20/20 Constant occlusion should be recommended
(6/6) visual acuity in each eye, it may be necessary to during times between office treatments for ARC.10
begin binocular treatment despite reduced acuity of Once the patient has started on an active therapy
an eye. At least 20/60 (6/18) acuity should be program, it is easier to motvate him or her to patch
achieved before proceeding with ARC therapy. As at home during the intervals between training.
discussed n Chapter 10, many patients show further Because ARC does not exist under monocular con-
improvement in visual acuity of the amblyopic eye as ditions, occlusion facilitates office training for the
a result of appropriate binocular training. successful elimination of ARC and the ultmate
Good monocular skills (saccades, pursuits, fixa- achievement of normal fusin.
tion, and accommodation) should be developed in
each eye before binocular treatment of ARC is ini-
tiated. Once monocular acuity and motility Binasal Occlusion
approach normal levis of performance, therapy Binasal occlusion is advocated by some clinicians
for ARC s introduced, which may involve occlu- for the prevention and treatment of ARC associated
sion, lenses and prisms, instrument training, train- with esotropa. Opaque strps of tape are cut to
ing in open space, and extraocular msete surgery. conform to the nasal reas of the patient's specta-
cle lenses. The tape can be tapered slightly to
allow for convergence at the nearpoint (Figure
OCCLUSION PROCEDURES 11-1). As a criterion for placement of the tape on
The purpose of occlusion in ARC therapy is to dis- the spectacle lens, Greenwald 11 recommended
lupt habitual ARC localizaron and prevent its rein- that "there be a visible pupillary reflex n both
forcement. Additional benefits of occlusion n eyes, just beyond the edge of each tape while the
cases of strabismus include breaking suppression patent fixates a near and far muscle light" (see Figure
and treating amblyopia. The method and schedule 11-1a and 11-1b). Greenwald11 contended that if
of occlusion selected for a patient depends on the the objective angle of deviation is reduced as a
age of the patient, the characteristics of the condi- result of wearing the binasal occluders, the prog-
bon, and several practical considerations. nosis for functional cure s fair to good. However,
if angle H increases, ". . . either eye being 'thrust'
behind the tape (so as to avod simultaneous
Constant Total Occlusion awareness) . . .," the prognosis is poor.11
ARC is associated with early-onset, comitant stra- We recommend binasal occlusion in some
fcismus. Whenever the onset of constant strabismus cases of esotropa and ARC, especially for chl-
pecedes age 7 years, the doctor should consider dren younger than 7 years. The purpose of the
.oclusin for the purpose of preventing the occur- method is to promote altrnate monocular fixa-
or continuance of ARC. The most common i of tion while preventng bifoveal stimulation. Ths
occlusion is constant total patching. Patch-; is also approach promotes equal visual acuty and full
effective in preventing suppression and >pia. If the abduction of each eye and, possibly, breaks down
patient has intermittent strabis- ARC. The patient will tend to use the right eye to
326 ChapteMI
a. RET
Lett Eye
Fixating
forms of occiusion, frequent office visits are rec-
ommended to ensure proper application and to
evalate effectiveness.
Graded Occiusion
Method of Revell
An attenuating filter or fogging lens placed before
the dominant eye may be used in some cases to
elimnate ARC. Such penalizaron (i.e., attenua-
tion) procedures are also known as gradea occlu-
son. In a few cases, when a dark filter (either
neutral-density or colored filter) is placed before
the dominant eye, ARC localizaron spontane-
ously shifts to NRC. A case was reported by
Revell12 in which he used a frosted lens (a graded
occluder) to forc a unilateral esotropic patient to
c. altrnate fixation to her nondominant eye. Using
Bagolini striated tenses to monitor the state of
correspondence, Revell12 observed that an ARC
response occurred when the dominant eye was
fixating, but an NRC response was found when
the nondominant eye fixated. If, in fact, there is a
shift to NRC when the strabismic eye fixates, the
patient should be instructed to wear a full-time
Right Eye graded occluder on the dominant eye to reinforce
Fixating
NRC. The least amount of attenuation is pre-
scribed that allows constant fixation with the
FIGURE 11-1B'masal occiusion in the case of esotropa of the rght nondominant eye. A Fresnel prism, with power
eye (RET). a. Hirschberg illustrations. b. B'masal occluson with cor- equal to or exceeding the deviation, is also
neal light reflex seen in each eye. c. Patching width increased for left
eye to encourage fixation with the right eye. placed before the dominant eye, thus providing
bifoveal stimulation and, over time, possibly
development of normal fusional abilities. The
fixate targets in the right field of gaze and the left patient wears the prism for several months to
eye for targets in the left field. The temporal reinforce NRC and central fusin. If long-term
peripheral field of each eye is stimulated, so the prismatic neutralization of the deviation is not
patient experiences his or her full field of visin cosmetically acceptable, the patient should be
(i.e., panoramic visin).3 If there is strong ocular referred for surgical correction of the deviation.
dominance and the patient resists alternating fixa- The mechanism for a shift in correspondence is
tion, then the tapes should be moved to break the unknown, but the shift is consistent with Bagolini's
unilateral fixation habit. The tape on the domi- concept of ARC in natural environments and NRC
nant eye should be moved to obscure the central in unnatural ones, a versin of the sensory adapta-
field and the tape on the nondominant eye moved tion theory.13 Because the patient is unaccustomed
a corresponding amount in the same direction to fixating with the strabismic eye, latent NRC local-
until altrnate fixation is achieved (see Figure ization is stimulated. We recommend checking for a
11-1c). To be effective, the spectacles, of course, change in correspondence, by use of forced alterna-
must rest in the proper position on the patient's tion of fixation, every unilateral esotrope and exo-
face. This requirement is a major disadvantage of trope with ARC. If the change in correspondence is
the method, especially with highly active chil- verified with Bielschowsky afterimages (Ais) or
dren. Another problem is that some children Bagolini striated lenses, then this graded occiusion
resort to frequent and large head movements to and prism compensation can be attempted with rea-
achieve altrnate fixation.3 These head move- sonable hope of success.
ments may be cosmetically distracting. As with all
Chapter11 327
TABLE11-1. Training Techniques with the TABLE 11-2. Clinical Characteristics Favorable for
Mayor Amblyoscope Classic Techniques for Treating Anomalous Retinal
Correspondence (ARC)
cess with classic techniques requires a therapist Vertical Displacement of Targets (T11.3)
skilled in communication with children, particu- Vertical displacement of the targets s another
larly storytelling. Other classic techniques can be amblyoscopic technique that may help to
introduced for the sake of variety and interest as achieve superimposition at the horizontal angle
weli as their therapeutic benefit. of deviation (angle H). For example, the left eye
may fixate the star while the Synoptophore car-
Macular Massage (T11.2) riage arm for the right eye s elevated to cause a
The method of macular massage s another classic displacement of the circle above the star. The two
amblyoscopic technique, which is described n the images might then be aligned subjectively at
following example. In a case of esotropa of 15A of angle H, provided enough base-out prismatic
the left eye with HARC (subjective angle of zero), compensation s given; this principie assumes
the circle seen by the right eye would be moved that peripheral retinal stimulation has triggered
back and forth from approximately 10A base-out to NRC localizaron. The therapist gradually reduces
20A base-out, approximately 5A to either side of the the vertical displacement n an attempt to allow
objective angle. The speed of movement may be the patient to superimpose the circle and star.
varied from slow to fast. Care should be taken to Often, the targets quickly seprate due to horror
avoid the subjective angle, because the ARC would fusionis as the circle target invades the foveal
be reinforced. The moving mage is on the dominant rea. This technique s repeated until the targets
eye, because NRC is more likely to occur when the jump apart less often. When superimposition is
nondominant eye s steadily fixating. achieved with the left eye steadily fixating, the
Initially, the two images are seen in different technique is repeated with the right eye steadily
locations. At some point, more or less suddenly, fixating.
the movements of the circle reach the star. When
the patient s able to report that the circle is Altrnate Fixation (T11.4)
superimposed on the star as the targets pass the Altrnate fixation on the amblyoscope s a tech-
objective angle, NRC s being elicited. Some nique that may help to break ARC. This technique
patients may report the binocular triplopia demonstrates an ncongruity between the patient's
response as ARC is broken down and NRC local- mage perception and eye movements. The targets
ization occurs. Because the patient's angle of are set n a position of neither the objective angle
deviation in the amblyoscope may vary, the thera- or the subjective angle but at a point usually
pist should not rely completely on the prismatic between the two. The patient is instructed to fixate
scale. Rather, he or she should also observe the alternately the star and the circle, for example. At
corneal light reflections to monitor the angle of first, the therapist may have to flash the targets
deviation (as in Hirschberg testing) during this alternately to help the patient get started. With
training. Better yet, the therapist should verify that altrnate fixation, the ARC patient usually sees the
the targets remain at the objective angle by the images jumping and has the feeling that his or her
exclusin douse test. In this test, one eye is eyes are moving. The patient alternately fixates as
occluded by shutting off the light of the instru- rapidly as possible for several minutes. This tech-
ment to that eye. A movement of the nonoc- nique tends to disrupt stable localizaron of the
cluded eye would be evidence of a manifest two mages. The targets then are moved slowly to
deviation, as n the unilateral cover test to detect the subjective angle, where they appear superim-
strabismus. posed. However, the patient soon becomes aware
When macular massage s effective in breaking that eye movements are necessary to fixate each
ARC with the nondominant eye fixating, the dom- target. The targets then are placed at the objective
inant eye should then be given the opportunity to angle, and the patient realizes that eye movements
fixate the stationary target. The technique then is are no longer necessary to fixate each target alter-
repeated with the oscillating target clued to the nately. This mismatch in kinesthetic-perceptual
nondominant eye. NRC s less likely to occur feedback helps to break ARC localizaron. In the-
when the habitually dominant eye is fixating and, ory, the patient will now be more likely to respond
consequently, superimposition of the targets at successfully to other classic amblyoscopic tech-
angle H may be more difficult to achieve than niques such as flashing targets at the objective
during nondominant eye fixation. angle (T11.1).
332 Chapter11
According to this technique, the patient tries to sockum optical method of disrupting ARC between
maintain binocular luster (indicating NRC) while daily home training sessions (see the section Opti-
targets are introduced at the edge of the peripheral cal Therapy). Simple occlusion or binasal occlu-
visual field. Placing targets initially n a superior sion may serve the same purpose. Achieving
quadrant seems to work best. If a split-field maximal results n children by training for NRC in
response results, the object is removed from the this manner may take between 1 and 3 months.
patient's view, and he or she is instructed to per-
ceive luster in the formless field as previously. The Afterimages at the
process of slowly introducing an object into the
Centration Point (T11.9)
periphery is repeated until the patient is able to
maintain luster as the object approaches the cen- The technique of using Ais at the centration point
is similar to the open-space luster technique
tration point. When objects are placed in the cen-
(T11.8). The Hering-Bielschowsky test is the rec-
tral visual field, there is a strong tendency to elicit
ommended procedure for generating Ais (see Fig-
a split-field response. At first, it may be necessary
to "overplus" the patient in relation to the fixation ures 5-40 through 5-44). First, positive Al training
distance of the screen. A blurred image may pro- is provided in dim room illumination, and then the
mote luster better than clear, distinct contours. This patient is trained with negative Ais in normal light-
training process is repeated until the patient is able ing conditions. This s similar to training in the Syn-
to maintain the perception of luster when a small optophore, except that the patient views the Ais n
target (such as a black dot) and, later, complex tar- open space. The first goal is to have the patient
gets are centrally fixated. perceive a perfect cross for both the positive Al and
With the appropriate addition lenses in place, the negative Al. With a centration-point add n
fusin training can proceed at the centration place, the esotropic patient initially views a blank
field at the centration point while trying to hold a
point. Theoretically, the patient has sensory ortho-
perfect Al cross (NRC) n perception. If NRC occurs
phoria in relation to the fixated target; normal
color fusin is indicated if the patient continually under blank field conditions, then targets and real
objects are moved toward the centration point as
notices luster. There is no assurance, however,
that central fusin is actually being developed. It the patient attempts to maintain NRC localizaron.
may well be that only peripheral fusin exists at The final goal with this technique is for the patient
this stage of treatment. Consequently, the luster to hold a perfect Al cross while bifixating a variety
of targets at the centration point.
method can be refined by projecting small red
Hugonnier et al.23 recommended a free-space
and green targets on the screen to monitor for
central suppression. training technique called direct attack at the objec-
Motor fusin training can be started once nor- tive angle in space (Figure 11-7). A target such as a
mal central sensory fusin is demonstrated. Only pencil point is placed at the centration point, and the
small amounts of vergence demand are introduced patient attempts to see a Hering-Bielschowsky cross
superimposed on the tip of the pencil. This picture is
at first, because the patient's ability to maintain
NRC is very tenuous; an ARC response is likely to an ndication of NRC, but the unilateral cover test
recur with any change n sensory or motor fusin should be performed, because the Al might be seen
with NRC while the pencil tip is seen with ARC. A
stimulation. The best way to induce vergence eye
movements is to have the patient move slowly movement of the uncovered eye on the unilateral
back and forth (only a few centimeters at first) from cover test would indcate ARC. In this eventuality, a
the screen while attempting to maintain fusin of higher plus add and a closer training distance should
be attempted. Bagolini lenses can be used for further
the target. Peripheral fusin targets (e.g., large
Brock red and green rings) may be required ini- training (see Figure 11 -7c and 11 -7d).
tially but, eventually, the patient should be able to
fuse small targets while he or she is moving back Other Combinations
and forth. Sensory and motor fusin training con- Many combinations of techniques can be used in
tines until the patient has developed the maximal cases of ARC. Real images may be provided by tar-
range of motor fusin under these conditions. gets such as black dots, anaglyphs, vectographic
In combination with the binocular luster tech- targets, and a penlight. These may be used together
nique, Ludlam18 recommended using the rockum with entoptic phenomena or Ais. Only a few repre-
338 Chapter 11
O.S.
O.D.
. PENCIL
sentative techniques can be discussed here, as the Haidinger Brush Technique (T11.11)
number of possible variations and combinations s The combination of the HB, a transferred Al, and a
legin. black dot sometimes is useful in ARC therapy (see
Figure 5-45). An Al is generated on the fovea of the
Prism-Rack Afterimage Technique (T11.10) right eye. The centration-point add s used to allow
Ronne and Rindziunski 24 reported a prism-rack for bifixation n open space; the right eye is not
Al technique. This method nvolves simply the occluded n this training technique. A device to
placement of a prism bar of horizontal prisms genrate an HB (e.g., Bernell Macular Integrity
before one eye while the patient s perceiving Tester-Trainer) is placed at the centration point. In
Ais. The prism bar should be slowly racked up the case of a patient with a left esotropa and
and down as the patient reports any changes in HARC, for instance, the patient should fixate with
Al localizaron. Ronne and Rindziunski 24 found the left eye so that the HB is on the black dot
that on Hering-Bielschowsky testing, a noncross (assuming central fixation); the transferred Al
may become a cross, in some cases, as a result would be seen to the left of the HB (ARC localiza-
of the introduction of various prisms. Possibly, tion to point a in the left eye). A flashing light near
covariation is stimulated with this technique, or the right eye intensifies the perception of the trans-
wexcjortectiqn of the deviation with prisms may ferred Al. The patient is nstructed to try mentally to
stimulate an NRC response. When an NRC reduce the angle of anomaly so that al I the images
response (a perfect cross) occurs, the patient (dot, HB, and Al) are superimposed (NRC localiza-
attempts to hold it as other prism powers are tion). The use of a pointer for tactile or kinesthetic
introduced in small increments. This technique stimulation and feedback often is helpful in this
can be performed with a blank field, f neces- type of training. It s hoped that visual stimulation
sary, or with real targets in open space using a with an HB and Al will help to break ARC localiza-
centration-point add. tion. When the patient achieves NRC localizaron
Chapter 11 339
point a 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.)
using a dot, other real targets of various sizes and ARC (see Figure 11 -7). Because most cases of stra-
complexity are ntroduced. bismus with ARC show HARC on the Bagolini
lenses, the patient sees, as though orthophoric,
Bagolini Lens Technique (T11.12) response with the light centered in the X (angle 5 =
Bagolini lenses with prisms can be used in a later 0) (Figure 11-8a). If the full compensating base-out
stage n open-space training for the elimination of prism is worn, the image of the light is now on the
340 Chapter11
should be sensitizad to changes in convergence and in-office until the patient can hold nearpa
using accommodative convergence. Several ses- alignment and perfectly crossed Ais for appra
sions of training may be necessary for this sensitiza- mately 5 minutes. The doctor can verify bifov
tion phase, to allow development of the patient's alignment and covariation by testing with Bagol
awareness of convergence eye movements, an lenses and the unilateral cover test. In this examp
important source of feedback. further management might include constant pah
The next step s to apply Hering-Bielschowsky ing of an eye between therapy sessions. After gnt
Ais to provide visual feedback when covariation is convergence has been achieved, standard vergen
occurring. The Ais will appear uncrossed or dis- training can proceed at near using lose prisn
placed (ARC) when the eyes are in the exotropic Vectograms, Tranaglyphs, and binocular accomir
position. When fusional convergence is stimulated dative flippers. Extraocular muscle surgery might 1
during the next step in the technique, the patient recommended, depending on the results of the se
will see the Ais joining together to become a per- sory and motor fusin training. (See Chapter 14 fe
fect cross (NRC) as the eyes move toward bifoveal discussion of visin therapy for exo deviations.)
alignment on a nearpoint target. This visual feed- Occasionally, an exotropic patient with Al
back is a strong incentive for the patient to con- may require amblyoscopic sensory training simil
tinu exerting fusional convergence. to that gjven in esotropa with ARC. This happe
The final phase in this technique s to stimulate in some cases of large-angle constant exotrop
accommodative convergence sufficiently n the with deeply embedded ARC when the gross ca
attempt to trigger a fusional (disparity) convergence vergence technique is unsuccessful. Open-sp
response. Merely stimulating accommodative con- alignment by means of base-in prisms and trainii
vergence with minus adds cannot be expected to may be tried, but this usually s not as successful;
result in a shift of correspondence, 7 but it may when the eyes are actually n the ortho positic
recruit a fusional vergence eye movement that is (i.e., with the minus lens and gross convergeix
associated with covariation. For example, assume method). Training n a reduced environment of ti
that a 12-year-old boy has a comitant, constant, major amblyoscope for exotropia follows the san
alternating exotropia of 40A at far and near with principies as are applcable to esotropa.
HARC. With visin training, the patient is aware of
eye movements, particularly accommodative con-
vergence, but he cannot yet fuse intermittently at SURGICAL RESULTS IN CASES
near. Hering-Bielschowsky Ais are applied and
OF ANOMALOUS RETINAL
appear uncrossed (ARC). A -2.00-D add is placed
before the patient's glasses (using Halberg clips) to
CORRESPONDENCE
reduce the angle of deviation and provide a stimu- Surgical correction of strabismus may result i
lus to accommodation. With the minus add n changes n correspondence, even in adults. If NRi
place, the resultant deviation is 30A exotropia. The existed prior to strabismus surgery, however,
patient s asked to look far away and cise his eyes. NR<will persist after the operation. 25 Often,
A small, detailed, colorful target (e.g., a sticker on a surga correction of strabismus with HARC
stick) s held just beyond the patient's nearpoint of results in microtropia with HARC.26 However,
accommodation. He s asked to open his eyes, normalizatia of correspondence n esotropic or
focus rapidly on the target, and to try to "pul the exotropic AR<cases may occur after an
eyes together." This s done while sensing the cross- operation.25~29
ng of the eyes (kinesthetic feedback) and joining Rutstein et al.25 reported a retrospective analysisc
the Ais (visual feedback). Similar to a personal exer- 20 strabismic patients who showed presurgical ARC
cise trainer, the therapist gives strong verbal encour- Seven of these patients (35%) were found to hav
agement and feedback about performance, whether NRC postsurgically. Most of these patients were sui
or not there is alignment of the eyes. gically overcorrected for their strabismic deviatior
On the first few attempts, convergence may be esotropes became consecutive exotropes and exo
inadequate. The goal is for the patient to increase tropes became esotropes. Even slight undercorrectioi
convergence until the Ais join. As the training pro- of the strabismus is not likely to trigger the NR(
ceeds, different nearpoint targets are used for the response. These patients tend to redevelop HARC
sake of variety. The technique is practiced at home Two seprate studies reported that approximatelj
70% of surgically overcorrected esotropes (consecu
342 Chapter11
tive exotropes) developed NRC.27'29 Jampolsky30 has raised: "What is the price and the chance of suc-
also proposed surgical overcorrection as a way of cessfully training normal binocular visin?" Clini-
jolting the fusin mechanism, creating diplopia, and cians and patients valu this goal differently, and
awakening a dormant normal correspondence sys- there is nothing approaching a consensus of opin-
tem. He called this effect surgical orthoptics. in. In their extensive review of the literature, Wick
These reports are very interesting, especially in light and Cook22 estimated that approximately 50% of
of the positive results with prism overcorrection15"17; esotropic patients having ARC can be expected to
the same or a similar mechanism of action may be achieve normal binocular visin, provided that
responsible for the shift in correspondence. When de sufficient time (up to 12 months) is devoted to re-
Decker29 combined surgical overcorrection of esotro- education. On the basis of our experience, we do
pa with prism overcorrection so that patients had not prescribe visin therapy when we believe that
approximately 12A exo deviation, his results improved we cannot achieve cure (using all therapeutic
to 82% for developing NRC and 46% for a cure (or a approaches including surgery) within a year in a
partial cure) of the strabismus. However, surgical strabismic patient with ARC. We often accept
overcorrection of esotropa sometimes necessitates a patients, however, for 10 training sessions, to verify
second operation due to a cosmetically unacceptable the prognosis and assess the patient's responses to
consecutive exotropia, an undesirable outcome. active therapy. This is called diagnostic therapy.
Given these results, one possible strategy in cases If possible, we prefer to treat ARC by stimulating
of strabismus associated with ARC might be to covariation. The fusional vergence mechanism of
attempt a slight surgical overcorrection, 5A or less, shifting ARC to NRC often is applicable in exotro-
supplemented by prism overcorrection to ensure that pia up to 50A and esotropa of 20A or less. For
the patient is left with sensory exotropia or binocular exotropia, the gross convergence technique n
fusin. Fresnel prisms can be conveniently applied open space (T11.13) and the Flom swing tech-
postoperatively, with frequent changes as needed. nique (T11.7) in an amblyoscope can both be
We believe some pre- and postoperative visin train- used. In cases of exotropia, the Flom swing tech-
ing usually improves the chance of either permanent nique is applied to genrate convergent eye move-
functional cure or partial cure of strabismus. ments rather than divergence. For small-angle
The exact mechanism of the shift in correspon- esotropes who qualify for this method, Flom's
dence with surgery remains unknown. Sensory divergence technique offers a fair chance for suc-
results are essentially unpredictable. However, a cess within a reasonable period. Once the patient
few patients are left with intractable diplopia. 31
has learned to covary and use this mechanism
Flom et al.32 reported a detailed case study of a 37-
when straightening the eyes, the diverging ability
year-old ntermittent exotropic woman with covary-
seems to be permanent. Surgery, however, is some-
ing ARC. She showed an mmediate change in the
times necessary to reduce the magnitude of the
angle of anomaly with a surgical change in the ocu-
deviation. Regression is prevented by assigning
lar deviation. The investigators proposed that post-
retainer vergence exercises on a regular schedule.
operative diplopia served as a stimulus for the
(Refer to Chapters 13 and 14.)
change to normal or near-normal correspondence, a
Besides access to a major amblyoscope, the suc-
sensory mechanism. The result after two operations
cessful application of classic techniques requires
was a small exophoria with NRC when bifixating;
however, HARC persisted when fusin was dis- that the practitioner have considerable ski 11 in man-
rupted and an exotropia was manifest. Further aging children over a period of several months. The
research is needed to Ilumnate both the nature of techniques are not inherently entertaining. Regular
these changes in correspondence associated with amblyoscopic training, three to five sessions per
surgical and prism overcorrection and the nature of week, is time-intensive and, therefore, expensive.
spontaneous changes in the angle of deviation. 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
CASE MANAGEMENT children. Often the prism spectacles are not accept-
When considering treatment of constant strabis- able for full-time wear, particularly at school, so the
mus associated with ARC, the question must be patient is given constant occlusion during school
hours and is instructed to wear the prism spectacles
Chapter11 343
at home for 3-4 hours per day. If and when NRC s worn for 10 minutes and resulted n an eso move-
established, the prism power is reduced to neutral- ment on the altrnate cover test: Prism adaptation
izing prisms. Home and in-office training activities had occurred. The procedure was repeated with a
help to consoldate normal sensory and motor total of 50A base-out prism with the same result as
fusin at this point (see Chapters 12-14). Extraocu- before. When a total of 60 A was worn for 30 min-
lar muscle surgery may be necessary to achieve utes, there was no eso movement on the cover test.
comfortable binocular visin, unless large amounts The patient then was instructed to wear the over-
of prisms are worn. Using a combination of thera- correcting prism spectacles for 30 minutes per day
peutic options, many patients with constant strabis- while performing active visual tasks. At all other
mus and ARC can develop good binocular visin waking hours, the patient wore a patch on an alter-
and maintain straight eyes within 3-6 months. nating daily schedule.
The prognosis for a complete or partial cure of After 2 weeks, the patient again showed an eso
strabismus with ARC can conservatively be esti- movement with the altrnate cover test. A total of
mated at 50% if these recommendations are fol- 80A base-out prism was prescribed for daily wear
lowed. Frequently, the result of therapy in cases of of 30 minutes each day along with patch i ng. After
long-standing ARC s microtropia. The patient may 1 month, there was an exo movement on the cover
achieve fair stereopsis (e.g., 200 seconds) and test. The Fresnel base-out prism power was
almost normal fusional vergence ranges despite reduced to 70A, and the same rgimen as was used
the presence of ARC with a small angle of anom- previously was carried out. After 2 months, NRC
aly. This outcome can be considered a partial cure was found with the major amblyoscope (angles H
and is, in our opinin, clinically acceptable. When and Sapproximately 40A).
a patient has successfully undergone visin ther- At this juncture, the second phase of the therapy
apy to establish NRC and there is no microtropia, was initiated. Overcorrecting prism of 60A was pre-
the therapeutic goals next involve breaking any scribed for 30 minutes per day, with constant
remaining central suppression and developing patching at all other times. In-office training tech-
good visual skills. Chapters 12-14 and 16-20 dis- niques began with peripheral first-degree and sec-
cuss the appropriate visin therapy techniques for ond-degree targets on an amblyoscope and
achieving these goals. sensory and motor fusin training at the centration
point. Home training included monocular pencil
saccades and accommodative facility training with
CASE EXAMPLES Hart Charts. With training, the fusional vergence
amplitudes increased to 30 A base-out and 15A
Case 1: Prism Overcorrection in base-in from the objective angle, but the patient
Esotropa was unable to appreciate stereopsis, although she
Christenson33 presented a case of a 6-year-old girl did report SILO ("small-in" with base-out prisms
with a history of an eye turn since the age of 3 and "large-out" with base-in prisms). Fusional ver-
years. This case demonstrates the efficacy of prism gence training around the objective angle contin-
overcorrection combined with visin training and ued n the open environment usingVectograms.
extraocular muscle surgery. There was no previous After a total of 36 office visits, the diagnosis was
treatment. The onset was gradual, but the strabis- comitant, constant, alternating esotropa of 30A at
mus soon became constant. The diagnosis of the 6 m and 40 cm; there was NRC and a large
deviation was comitant, constant, alternating (left fusional divergence range. At this point, the patient
eye dominant), esotropa of 30A at 6 m and 40 cm. was referred to an ophthalmologist for extraocular
Cycloplegic refraction revealed the following: muscle surgery. The operation conssted of a 5.5-
mm bimedial rectus recession. Postoperatively, a
Oculus dexter (OD): +1.00 -1.00 x 150, 20/20 (6/6)
monofixaton pattern of the right eye was ndicated
Oculus sinister (OS): +1.00 -1.00 x 035, 20/20 (6/6)
by the unilateral cover test and the 4A base-out test
Associated conditions included HARC (Bagolini stri- at far. A small right eso flick was seen on the unilat-
ated lens test), no motor fusin, and no stereopsis. eral cover test, with the paradoxical finding of 10A
A prism adaptation test was performed. Fresnel base-in on the altrnate cover test (i.e., presence of
prisms were placed on plano lenses in a frame fit- an exo deviation during dissociation). Suppression
ted to the patient. A total of 40A (20A each eye) was of the right eye was ndicated with the 4A base-out
344 Chapter11
test. However, 2A of esophoria was found at the 40- presson on the red-green televisin trainer. Extraocu-
cm fixation distance. Amb/yoscope testing indi- lar muscle surgery reduced the deviation to 20A, after
cated NRC, but stereopsis was not found with which the patient became exophoric. Postoperative
either the Reindeer or Randot tests. visin therapy consisted of base-out training with the
Ten weekly office training visits followed the televisin trainer, single Aperture-Rule Trainer, and
postoperative evaluation. Vision training was done various chiastopic fusin techniques (see Chapters
with Vectograms and stereoscopes to attempt to 12, 14, and 18). The patient had no symptoms, and
break central suppression and increase fusiona! ver- all visual functions normalized.
gence ranges. Although vergences were strength- The mportant point of this case s that although
ened with training, there was still no stereopsis; the ARC may be present when exotropia is manifest,
4A base-out prism test revealed a small central sup- NRC may be found when the eyes are in the ortho
pression zone of the right eye. Subsequently, the position.
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: Case 3: Flom Swing Technique for a
Small-Angle Esotropic Patient
OD : +0 .5 0 - 1 .0 0 x 1 7 0 Ms. B, a 23-year-old student, was referred by an
OS: +0.50 -1.25 x 010 with +2.50 adds optometrist, who fitted her with rigid, gas-perme-
With this prescription, the patient maintained an able contact lenses, because of her persistent
eso monofixation pattern at far and 2A esophoria at asthenopic complaints that seemed to be related to
near. Follow-up evaluation 2 years later showed deficient binocular visin. She reported headaches
the deviation to be stable. This patient's binocular initiated by reading, itching and burning eyes that
status satisfied most of Flom's criteria in the increased in intensity throughout the day, and
"almost cured" category.34 There was clear, com- reduced reading time. University studies, however,
fortable, single binocular visin present at all dis- required her to read several hours per day. She
tances and normal ranges of motor fusin but lack reported good general health and use of no medi-
of stereopsis. The patient was happy with her cations, but she had had surgery for esotropa at
improved binocular status. approximately 2 years of age.
Ms. B's visual acuity was slightly reduced with
her contact lenses: OD, +2.00 DS 20/25; OS, +1.50
Case 2: Stimulating DS 20/25". The strabisrnus evaluation revealed a
Covariation in Constant Exotropia constant, comitant, alternating (left eye preferred for
Wick35 presented a detailed case report of a 13- fixation) esotropa of 12A at 6 m and 40 cm with the
year-old patient with constant, alternating exotropia contact lenses. Cosmess of the strabismus was
of 45A and HARC on all tests. Constant occlusion good. Sensory fusin testing indicated HARC, deep
was prescribed between training sessions (both central altrnate suppression, and 400 seconds on
in-office and home). He used a variation of the the Stereo Fly test. Although her accommodative
gross convergence technique (T11.13) to stimulate amplitude was normal for her age (10 diopters [D]
fusin at near and covariation to NRC. Minus in each eye), binocular accommodative facility was
2.00-D adds were worn to induce convergence at reduced. Ms. B took 2 minutes to clear 20 cycles
far. Ais were used so that correspondence could be using +1.50-D flippers. A cycloplegic subjective
monitored during forced convergence at near. The refraction showed the following refractive error:
minus additions were not used at near. The Pola-
OD: +2.50 -1.75 axis 1 76 20/20 OS:
Mirror (see Chapter 12) was included so that sup-
+2.25 -3.00 axis 017 20/20
pression could be monitored during convergence
while the patient maintained a perfect Al cross. The Keratometry readings confirmed the astigmatism:
patient was able to achieve this goal after 2 weeks
OD: 42.50 @ 170; 44.75 @ 80
of visin therapy.
OS: 42.00 @ 5; 45.37 @ 95
Red-green televisin antisuppression training then
was perforrned in conjunction with Ais at far, using Ordinarily, patients having a small-angle con-
the -2.00-D addition lenses. After 3 weeks, the stant esotropa, central suppression, and ARC are
patient was able to achieve an Al cross without sup- free of binocular visin symptoms. However, n
Chapter11 345
this case, we suspected that the combination of In an attempt to increase fusional control and
high visin requirements, only rudimentary binoc- comfort, the following prism spectacle lenses were
ular visin, accommodative infacility, and uncor- prescribed:
rected astigmatism caused her visual symptoms
OD: +2.25 -1.25 axis 175 3A with base-out 20/20
and reduced reading time. Rather than just treating
OS: +2.25 -2.75 axis 017 3A with base-out 20/20
this patient on a symptomatic basis, we suggested
that she could attempt a functional cure of the stra- Also, +1.50-D Fresnel flat-top adds were
bismus and the accommodative disorder n addi- applied to reduce the deviation at near. Ms. B dis-
tion to wearing a fu 11 correction for her refractive continued contact lens wear except for some
error. Ms. B was agreeable to this approach. social occasions.
In-office training n 1-hour weekly sessions con- The patient continued the fusional vergence
sisted primarily of the divergence technique (Flom training with the Bernell Mirror Stereoscope at
swing) on an amblyoscope (T11.7). The central sup- home. Vectograms (Mother Goose and Spirangle)
pression was overeme by the automatic, rapid, also were ntroduced with a total training time of 30
altrnate flashing and by increasing the illumination minutes per day. Accommodative facility training
to the right (nondominant) eye. During the initial was discontinued, because the patient had achieved
training session on the amblyoscope, Ms. B appreci- normal monocular and binocular facility. Vergence
ated stereopsis on the swing slide, held both suppres- ranges continued to increase over a 1-month period
sion controls in perception, and demonstrated some and then stabilized. Because the patient was essen-
divergence skill as base-in demand was gradually tially symptom-free at this point and vergence skills
increased. She was unable, however, to diverge her had been trained to a high stable level, Ms. B was
eyes through the entire angle of deviation until the given retainer exercises to perform for 30 minutes
third training session. For 20 minutes per day of twice weekly using the Bernell Mirror Stereoscope
home training, a Bernell Mirror Stereoscope was and was released from therapy. Vergence skills gen-
assigned with large second- and third-degree fusin eral ly regress faster n strabismic cases as compared
targets. She achieved sensory fusin with these tar- with phoric cases owing to the resultant stress on
gets at her subjective angle, then attempted to build fusional vergence and recurrent suppression, so a
fusional vergence ranges using sliding vergences, vigorous retainer program was required.
with emphasis on divergence. She also spent 10 min- Ms. B was released from active therapy com-
utes per day training monocular accommodative pletely symptom-free and fusing normally, with
facility using Hart Charts and accommodative flipper bifoveal fixation 99% of the time, a cured case by
lenses. Flom's criteria.34 A periodic schedule of progress
Progress n building divergence and accommoda- checks was initiated at 6-month intervals. The
tion was rapid. After 4 weeks of in-office and home patient occasionally lost fusin at intermedate dis-
training, Ms. B could voluntarily straighten her eyes tances but not at far or at near (even without the
in the open environment and hold them aligned at far bifocals). She experienced dplopia at these times;
and near for several minutes. She noticed an ncrease blinkng initiated the required vergence eye move-
in perception of stereopsis when the eyes were ment to align the eyes properly. This finding suggests
straight, but there was also a sense of eyestrain. that NRC was present, even when fusin was lost.
Monocular accommodative facility was within nor- The Fresnel adds were removed without a notce-
mal limits. By cover test, she showed an intermittent, able reduction of visual skills. In summary, the
comitant, 12A esotropa of the right eye at far and patient gained normal stereopsis and visual func-
near. Stereopsis had increased to 40 seconds of are at tions within a reasonably short period of visin
40 cm (Stereo Fly test) when she voluntarily aligned training. In this case, partial prism compensation
her eyes. Response time, however, was slow. After 8 was also necessary to achieve mximum results.
weeks of training, normal sensory and motor fusin
was maintamed on a reflex level for most of the day.
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Association, Acapulco, Mxico. Fells P, ed. St. Louis: Mosby; bismological Association. Fells P, ed. Marselles, Fr.:
1971:227-234. Diffusion Genrale de Librairie; 1976:291-294.
15. Fleming A, Pigassou R, Garipuy J. Adaptation of a method 31. Gruzensky WD, Palmer EA. Intractable diplopia: a clini
of prismatic overcorrection for testing strabismus in chil cal perspective. Graefes Arch Clin Exp Ophthalmol.
dren one and two years od. J Pediatr Ophthalmol. 1973; 1988;226:187-192.
10:154-159. 32. Flom MC, Kirschen DG, Williams AT. Changes in retinal
16. Amigo G. Present trends in orthoptics and pleoptics in correspondence following surgery for intermittent exotro-
Giessen. Am] Optom. 1970;47:713. pia. Am] Optom Physiol Opt. 1978;55:456-462.
17. Arruga A. The Use of Space Diagnostic Methods and of 33. Christenson GN. Treatment of esotropa with anomalous
Prismotherapy in the Treatment of Sensory Alterations of correspondence: a case report. J Am Optom Assoc. 1992;
Convergent Squint. In: The First International Congress 4:257-261.
of Orthoptists. St. Louis: Mosby; 1968:62-76. 34. Flom MC. Issues in the Clincal Management of Binocular
18. Ludlam WM. Lecture at San Jos Vision Training Seminar, Anomalies. In: Pediatric Optometry. Rosenbloom AA,
San Jos, Calif., 1970. Morgan MW, eds. Philadelphia: Lppncott; 1990:222-
19. Revell, MJ. Strabismus: A History of Orthoptic Tech- 223.
niques. London: Barrie & Jenkins; 1971:30-36. 35. Wick B. Visual therapy for constant exotropia with anom
20. Wick B. Visual therapy for small angle esotropa. Am ] alous retinal correspondencea case report. Am] Optom
Optom Physiol Opt. 1974;51:490-496. Physiol Opt. 1974;51:1005-1008.
chapteriz / Antisuppression Therapy
Suppression s active cortical inhibition of all or sion. Suppression is an active process to prevent
part of one eye's binocular field under binocular diplopia and relieve visual discomfort. Gener-
viewing conditions. The perception of a sup- ally, the longer Suppression s present, the
pressed image cannot always be rejuvenated by deeper it s and the more difficult is its treat-
simply calling the patient's attention to that ment. Many heterophoric patients with vergence
image. Suppression occurs when sensory or anomalies also have some degree of suppres-
motor fusin s overly taxed. Uncorrected ani- sion. Suppression, therefore, is an mportant
sometropia, aniseikonia, amblyopia, and strabismus consideration in the treatment of most binocular
are conditions often associated with suppres- visin disorders.
348 Chapter12
More than 100 years ago, Javal pointed out the rate suppression, the patching rgimen can be
importance of antisuppression to effect a binocular relaxed somewhat, with the patient wearing the
cure in cases of strabismus.1 Antisuppression train- patch part of the day but always under concen-
ing was fundamental to his therapeutic approach trated seeing conditions, such as when reading,
and still s considerad to be of primary mportance writing, and watching televisin. If the suppression
in the management of all binocular visin anoma- is only shallow, the patch need be worn only when
lies. Javal believed that obstacles to sensory fusin reading or watching televisin in the evening for 1
should be removed before efforts are made to align or 2 hours. Some cases of shallow suppression
the eyes with vergence training or surgery. One of require only antisuppression training activities,
his basic principies of effective visin therapy is without the necessity for occiusion.
providing targets that have suppression clues (con- Graded occiusion may be applied when sup-
trols) for monitoring and training purposes. Appro- pression s shallow. (See Chapter 5 for testing the
priate targets are presented either with an ortho intensity of suppression.) In most cases of deep
demand or with forced vergence demands. When suppression, however, an opaque occluder is
suppression of an eye is noted, active antisuppres- required between active therapy sessions. Note
sion techniques are immediately used to enliven that these active therapy sessions may be either
the suppressed image and establish sensory fusin. in-office or out-of-office (home training). When
Once sensory fusin s established, sensory and suppression is modrate, a graded occluder may
motor fusin demands can be increased until a be prescribed to promote fusin, but only in cases
suppression response occurs again. This antisup- of anisometropic amblyopia or in patients whose
pression process is continued until suppression is strabismus s only occasional. Graded occiusion
completely eliminated within a zone of clear, sin- can break suppression while reinforcing sensory
gle, comfortable binocular visin. Theoretical and motor fusin. When suppression is only shal-
aspects of suppression and testing procedures are low, mild attenuating occluders may be effective
discussed in detail in Chapter 5. This chapter n promoting sensory fusin. The concept of
describes (1) general approaches (passive and active) graded occiusion s consistent with the natural-
to breaking suppression, (2) targets and stimulus ness concept of testing the intensity of suppres-
variables for breaking suppression, and (3) specific sion (see Chapter 5). In short, the deeper the
antisuppression techniques. suppression, the more unnatural the occluding
procedure should be. For example, a dark red
lens could be worn over the dominant eye when
OCCLUSION ANTISUPPRESSION the suppression is moderately deep. If the sup-
THERAPY pression is merely shallow, a light pink lens over
the dominant eye may suffice to break the sup-
There are two antidiplopia mechanisms in strabis- pression of the nondominant, suppressing eye. A
mus: anomalous retinal correspondence (ARC) and neutral-density filter of appropriate transmittance
suppression. Just as in ARC, patching an eye pre- can also provide effective graded occiusion and
vents suppression because it does not occur under can be attached to the spectacle lens with adhe-
monocular viewing conditions. Therefore, occlu- sive tape.
sion can be thought of as a passive form of visin
therapy to prevent and break suppression. Sup-
pression is an active process that tends to deepen
GENERAL APPROACH TO
with abnormal visual experience. Occlusion helps
ANTISUPPRESSION TRAINING
to break through suppression by preventing its
reinforcement. There are hundreds of antisuppression training
The typical occiusion rgimen in cases of deep Instruments, targets, and techniques. Many training
suppression associated with constant strabismus is methods are variations of tests used to detect sup-
.constant patching at all times during which visin pression, such as those involving stereoscopes and
training is not being performed. Occlusion allows colored filters. Although only a few antisuppres-
for maintenanceduring daily activity at school, sion techniques are presented, the concepts we
work, or playof the gains made during antisup- discuss can be applied to most innovative methods
pression training (active therapy). .In cases of mod- that a therapist originates.
Chapter12 349
Antisuppression Variables
When active antisuppression training is assigned, a TABLE12-1. Antisuppression Variables
number of mportant variables must be considered
in designing an appropriate training method. Fac - * Attention to target
tors that should be considered n training are usted * Brightness of target
inTable 12-1. Contrast of target
Color of target
Attention Slzeof target
The attention factor is a very important consider- FtasMng of target
ation n the treatment of suppression. When the Movement of target
therapist presents a new target or device, each eye TactHe ana kinesthetc effects on suppression
should be occluded in turn, and all suppression Auditory effects on 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 differential brightness by direct llumination from a
can momentarily stop the suppression. Antisup- penlight or desk lamp to the target of the nondomi-
pression training s, therefore, an active process, nant eye. Background room llumination can also
and the patient is expected to exert mental effort to be lowered so that the dominant eye has a dimly
hold the suppression controls n perception. lluminated target. Figure 12-1 shows howthis prin-
Although attention s necessary, t alone s not cipie s applied to an Aperture-Rule Trainer. The
always sufficient to break through a suppression dominant eye can view the target n low llumina-
response. tion while the suppressed target can be lluminated
Because attention s such an mportant variable, with a penlight.
the therapist should select targets that are of interest
to the patient, particularly n the case of children. Target Contrast
Polarized or anaglyphic televisin trainers or read- Contrast between figure and ground s a factor in
ing bars are antisuppression nstruments that are the treatment of suppression. If the contrast s high,
popular with most patients. Cheiroscopic training there s less likelihood of suppression. Therefore,
can also pique the interest of children who enjoy the suppressing eye should be presented with a
drawing and tracing. For older children and adults, high-contrast target. For a number of reasons, sup-
we have found the Bernell 500 series of Tranaglyphs pression s more likely under natural seeing condi-
(see Appendix J for manufacturer information for tions, one reason being that figure-ground contrast
products Usted n this chapter) depicting sports fig- under such conditions is relatively low. Simplified
ures to be well designed for antisuppression training targets n a major amblyoscope with high contrast
while holding a patient's nterest. are less likely to be suppressed. For practical pur-
poses with home training devices, a neutral gray
Brightness overlay can be placed over the target of the domi-
The target before the suppressing eye should be nant eye to reduce its brightness; similarly, the
brighter than the target before the nonsuppressing contrast may also appear to be diminished, as
eye. This difference in the level of brightness must when a dark gray target appears on a light gray
be large if suppression is very intense (deep). Even background. This penalization of the dominant
patients who have deep suppression are unlikely to eye, as to brightness and contrast, helps to break
suppress when the dominant eye has a dim image suppression of the nondominant eye.
and the nondominant eye has a bright one. Differ-
ential brightness of the targets for each eye may be Color
created either by raising and lowering the lumi- Generally, colored targets hold a patient's attention
nance of the targets or by using graded (attenuating) better than do black and white targets. Targets usu-
filters before the eyes. Instruments such as the Syn- ally are colored for both eyes, but t may be helpful
optophore have rheostats for this purpose. Home to use a black and white target for the nonsup-
training and simple office devices can accomplish pressing eye and one that s colored for the sup-
350 Chapter12
o.s. O.D.
lus.2'3 Suppression of a flashing stimulus s diffi- patient's attention, tending to keep the target from
cult. Jampolsky4 suggested that a latency period s being suppressed.
needed for suppression and that a flashing pattern Movement of one target under binocular condi-
interferes with this period. One of the most power- tions can be accomplished in various ways. In the
ful methods of introducing intermittent stimuii is office, the major amblyoscope is ideal. Some mod-
flashing one or both targets using the automatic els have an oscillator switch; others require back-
flashing unit on a major amblyoscope. Some and-forth movement of the carriage arm. For home
deeply suppressing strabismic patients require this training, the patient may hold a mirror that s
level of intervention. Clinicians may prefer unilat- angled before one eye in such a way that he or she
eral flashing of the suppressed target to elicit its can superimpose two different objects in the room.
perception. Others prefer altrnate flashing to Getz5 suggested that a televisin be used for one
forc the suppressing eye to see the controls when eye while the other eye views an object n the
the dominant eye is occluded. Both types of flash- room through the mirror. Jiggling the mirror can
ing should be tried to discover which s more crate the desired target movement. (This tech-
effective in a particular case. We often use rapid nique s discussed in the section Hand-Mirror
automatic flashing in the amblyoscope, which Superimposition.)
seems to work well in most cases. At home, n case
of deep strabismic suppression, a circuit breaker Tactile and Kinesthetic Senses
can be put in the socket of a desk lamp, transform- Tactile and kinesthetic stimulation can be used for
ing it nto an automatic flashing unit. The iight antisuppression purposes. In many instruments,
from the flashing desk lamp can then be directed such as a Bernell Mirror Stereoscope or Keystone
onto the suppressed field in a Bernell Mirror Ste- Telebinocular, the therapist can ask the patient to
reoscope, set up with fusin targets at the patient's touch each eye's suppression control simulta-
objective angle of deviation. The patient s asked to neously using pointer sticks. The physical act of
make a conscious effort to hold al I the suppression touching can break through a suppression response,
controls n perception once they are seen. at least temporarily. The pointers also become sup-
Flashing can be easily accomplished n free pression controls when introduced nto the field of
space (the open environment) n several ways. The view. Cheiroscopic drawing is another well-known
therapist or patient can quickly cover and uncover technique that uses the tactile and kinesthetic
an eye with a paddle occluder. This popular tech- senses (Figure 12-3).
nique for breaking suppression can be applied to
many training nstruments if there are suppression Auditory Sense
controls n the field. Another method is simply ask- Auditory stimulation can be helpful and s an
ing the patient to blink one or both eyes when sup- effective way to hold a patient's attention. Therapy
pression occurs. This also helps to enliven a time may be reduced when auditory feedback
suppressed image, but it must not be carried on for devices are incorporated nto the training pro-
a long time as it results n visual fatigue. A pen- gram. Instruments such as the Wayne Perceptuo-
light-flashing technique that can be applied with motor Pen (discussed n Chapter 10) can be used
free-space instruments is illustrated in Figure 12-1 c. n conjunction with anaglyphic red-green filters to
These techniques are the most frequently used monitor suppression, and the sound of a buzzer
methods for breaking suppression and establishing can alert the patient when tracing s naccurate.
sensory fusin both n the office and at home. Home training using auditory clues can be
accomplished during cheiroscopic drawing by
Target Movement tapping of the pend tip to make a noise. The
Movement of the suppressing eye's target s effec- patient can tap the pencil to draw attention to the
tive for several reasons. First, noncorresponding tip; attending to the pencil tip tends to prevent ts
points are being stimulated by the oscillation of the being suppressed.
target. These points are less likely to be suppressed Involvement of the tactile-kinesthetic and audi-
than are corresponding points. Movement of the tory senses helps to break suppression more
target before one eye stimulates new retinal reas, quickly than would be the case if a patient merely
and the visual system generally responds to looked at stereograms without pointing. Use of the
change. Also, a moving target s apt to draw the tactile-kinesthetic and auditory sense tools allows
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.
the patient soon to become aware of the relation the therapist can include colored pencils, pencil
between motor performance and suppression. This movement, blinking of the suppressing eye (inter-
feedback enhances awareness of sensory fusin. mittent stimuli), and tapping of the pencil tip for
auditory stimulation. The therapist should bear in
Combina tions mind these antisuppression variables and apply the
More than one variable in antisuppression training appropriate features for a particular nstrument or
usually is used in any particular therapeutic tech- technique. In contrast, however, the therapist
nique. The effectiveness of a technique generally should not add so many variables that the patient
increases when several antisuppression variables becomes confused in a particular antisuppression
are included. With the cheiroscope, for instance, activity.
Chapter12 353
Four-Step Approach to
Antisuppression Training TABLE 12-2. 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). 1. Design an appropriate training environment. Select
the instrument, targets, and stimulus condtions.
Step One The patient shoutd not suppress more than 30% of
The first step s to design the appropriate training the time in a particular erwirenment.
environment for the patient's level of suppression. 2. Stimulate perception of the suppressed targets or
controls. Common stimuli are flashing targets, blink
The antisuppression variables listed in Table 12-1
ing, target movement, and pointing anel touching.
are used for this purpose. If suppression is deep,
3. Motvate the patient to exert mental effort, Set
the initial training environment should be rela-
tirne goals for suppression-f ree sensory fyson
tively unnatural (e.g., use of an alpha rhythm (e.g,, 1 min under specific stimulus and target con-
flasher [Translid Binocular Interaction Trainer], ditons).
major amblyoscope, red-green televisin trainer). 4. Increase the sensory and motor fusin demand.
If the suppression is shallow, a relatively natural Progress to smaller suppression controls and higher
training environment s appropriate (e.g., using vergence dernands. Prisms and tenses can be usedto
Vectograms, Brock string and beads, Pola-Mirror). extend the training range of a particular environ
In working with a specific nstrument, the therapist ment. The process is repeated with more chateng-
should select stimulus and target parameters that ing instrurnents or environmental condtions unttl
allow the patient to succeed at the antisuppression normal fusonal vergence ranges are developed and
task approximately 70-80% of the time. The the patient is free of foveal suppression.
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. approximately 1 digit per second. The initial goal
may be to reach the count of 10. When that is
Step Two achieved consistently, a higher number s chosen.
The second step s designed to stimulate percep- A practical goal s for the patient to avoid suppres-
tion of the suppressed image. When suppression sion for at least 1 minute under a particular set of
does occur, an antisuppression stimulus is applied training conditions. When accomplished, more
to break down the suppression response and challenging training conditions are given and the
enliven the suppressed image or control. Flashing process is continued (e.g., flashing of the target is
a target or an eye (intermittent light stimulation) s discontinued or brightness s diminished).
the most commonly used stimulus. Other impor-
tant antisuppression stimuli are blinking, move- Step Four
ment of a target, and pointing or touching. The The fourth and last step s ntended to increase the
type and strength of the stimulus must be appropri- sensory and motor fusin demand. Antisuppression
ate for the depth and extent of suppression. Simul- therapy also involves building the quality and quan-
taneous perception of al I targets or suppression tity of sensory and motor fusin, which s accom-
controls in the binocular visual field is the goal. plished by changing the target parameters listed in
Table 12-1 and varying the stimulus to accommoda-
Step Three tion and vergence. For example, smaller targets or
In step three, the patient s encouraged to make a controls are introduced with the goal of using
mental effort to hold the targets or suppression "fovea-sized" targets in the final stages of therapy.
controls n perception for a specified length of Lose prisms and accommodative flipper lenses can
time. For example, the patient s asked to count be ncluded to increase the motor fusin demand of
aloud slowly as long as both images are seen antisuppression tasks. The training goal s for the
simultaneously. When suppression occurs, count- patient to achieve sufficient fusional vergence
ng s stopped. Counting aloud provides conve- ranges without foveal suppression.
nient performance feedback to both therapist and As the limits of sensory and motor fusin devel-
patient. Each number s spoken at the rate of opment are reached with a particular instrument or
354 Chapter12
/<T*T>
TT
and should be shortened further or discontinued target is a good example (see Figure 5-7). With
there s any resultant sign of discomfort. The these second-degree fusin targets aligned at the
doctor should not prescribe TBI therapy for home objective angle of deviation in the ambiyoscope,
until there s certainty as to the patient's reac- illumination is ncreased for the suppressing eye
tions to the TBI and complete understanding of its and decreased in the dominant eye until the
proper use. patient can see all four wings simultaneously
most of the time (approximately 70-80%). Man-
Major Ambiyoscope (T12.2) ual or automatic flashing or target movement s
h many ways, the modern major ambiyoscope s used to break the suppression response when it
an ideal instrument with which to break down occurs. The patient makes a mental effort to hold
|Hthologic suppression associated with strabismus the controls in perception with sensory fusin as
and amblyopia. The intensity of illumination can long as is possible or to meet a specific goal (e.g.,
fcevaried over a large range. An automatic flashing 1 minute). As the patient makes progress, the llu-
t provides many options in the rate, periodicity, mination gradient between the two eyes s
and type of flashing. Some instruments come with reduced. Flashing is also used sparingly. The bug
Stanworth mirrors that allow targets to be pro- target also has "fovea-sized" suppression controls
jtcted into the open environment, thereby aiding on its body. As peripheral suppression s elimi-
transfer of learned visual skills from instru-ts to nated, a smooth transition can be made to central
natural seeing conditions. Also, sudes of arious fusin training, using the small dots to control for
sizes and parameters are available that are foveal suppression.
appropriate for patients of al I ages.
Chasing
tination Gradient and Flashing Another variation of antisuppression training using
cases of deep, extensive suppression, large tar- the major ambiyoscope s chasing, a break-and-join
and suppression controls are selected. A bug task. The technique stimulates both sensory and
356 Chapter12
Endpoint Suppression
1. Penlight fixaton with patient wearing red and
green filters, fn darkened room, and intermittent, After suppression at the objective angle has been
rapid occlusion of deviating eye eliminated, suppression-free fusional ranges, both
2. Same as step 1 but with red lens over fixating eye base-in and base-out, should be increased maxi-
(no green lens) mally. Endpoint suppression can be broken by very
3. Same as step 1 but with red lens over deviating eye rapid flashing of the suppressing eye so as not to
4. Same as step 1 but without intermittent occlusion break sensory fusin. Also, slight movements of the
5. Same as step \ but with pink lens over fixating eye target can be introduced by oscillation or by sim -
6. Same as step 1 but with pink lens over deviating ply jiggling the amblyoscope arm. When the sup-
eye pression control reappears, the vergence stimulus
7. Same as step 1 but with no tens over ether eye is further increased as the patient tries to keep the
8. Repeat of steps 1-7 but with normal room illumi- controls in view.
nation
9. Fixation of ordinary object in room while deviating
Penlight and Filters (T12.3)
eye is intermittently and rapidly occluded or
A powerful and convenient in-office technique for
blinked
establishing simultaneous perception (pathologic
10, Same as step 9 but without intermittent occlusion
or blinking of the deviating eye diplopia) with a strabismic patient involves the use
of a penlight and anaglyphic filters. The patient,
wearing red-green filters, views a bright penlight
held by the therapist n a dark room. Working at a
motor fusin. A second-degree target is set at the cise distance from the patient, the therapist moves
objective angle, and the llumination is adjusted to and blinks the light in an attempt to elicit a diplopic
crate the optimum training environment to mini- response. The patient can blink or rapidly cover and
mize suppression. Rather than providing a flash uncover an eye. If necessary, a vertical prism can be
when suppression occurs, the therapist moves a car- held by the patient in front of the suppressing eye to
riage arm of the amblyoscope to a new vergence move the image outside the suppression zone. The
setting, either base-in or base-out. This action prism itself can also be rotated to add another
breaks sensory fusin and creates a double image dimensin of movement. When diplopic images are
if the image is moved out of the suppression zone. seen, the patient exerts mental effort to maintain
The patient then slowly moves the other arm of the both images as the therapist backs away across the
amblyoscope to join the two images. Mental effort is room. In this way, both brightness and image size
encouraged so that the patient maintains simulta- are reduced. Background illumination can be raised
neous perception of the two images when diplopic to reduce contrast as training proceeds. Other varia-
and again when the two are joined into a single fused tions of this technique are usted in Table 12-4. The
image with all suppression controls present. As soon endpoint is to establish diplopia for lights and
as suppression is again reported, the therapist moves objects in a normal environment simply by using
the arm to a new vergence setting. This process con- the patient's visual attention.
tines until the patient no longer experiences sup- An effective variation of this technique is to add
pression when the images are fused. At this point, a prism equal in amount to the patient's objective
stimulus conditions are changed or new, more angle of deviation. Initially, the prism is held verti-
demanding second-degree targets are selected. cally before the suppressing eye to stimulate diplo-
The therapist should note that the patient may pia. When the double images are seen, the prism is
report sensory fusin before he or she moves the slowly rotated so the images are joined (.e., base-
amblyoscope arm an equal amount as compared out for esotropes and base-in for exotropes). The
with the vergence stimulus introduced by the ther - nondominant image should appear to move diago-
apist. This discrepancy s desirable, as it suggests nally toward the dominant one, assuming normal
that the patient is making fusional vergence eye retinal correspondence. As the moving image
Chapter12 357
Hand-Mirror Superimposition
CT12.4)
Hand-mirror superimposition, an excellent open- and target distances can be increased and less stimu-
environment mirror training technique described lating targets (e.g., vases and doorknobs) can be
by Getz,5 is particularly appropriate for deep, selected. This technique effectively stimulates super-
ttensive suppression. All the antisuppression vari- imposition (first-degree fusin) but, once that s
ables Usted in Table 12-1 can be applied, and t is achieved, t s mportant to move on quickly to
practical for use as a home training technique. other techniques that build higher degrees of sen-
Assume a patient has deep suppression of a left sory fusin.
strabismic eye. A hand-held mirror can be aligned
before the left eye at the bridge of the nose to view Cheiroscopic Games (T12.5)
a bright desk lamp. The right eye observes another The cheiroscope s a binocular visin training
stimulating target (e.g., a televisin) (Figure 12-5). instrument, a closed nearpoint space, n which
The patient can consciously attend to the televi- the two fields are separated by a diagonal mirror
sin program during this training, which makes (see Figure 12-3). The Mirror Stereoscope/Cheiro-
tfiis a popular technique. The training task is to scope from Bernell Corporation s available for
hold the lamp and televisin n simultaneous per- this purpose, as s the Single Oblique Mirror Ste-
ception and superimposition as long as possible. reoscope (SOMS) trainer. In most training situa-
The mirror can be angled so that the image of the tions, the dominant eye fixates a target field
lamp is seen in the same direction as s the televi- through the mirror while the suppressing eye
sin to promote bifoveal stimulation. Retinal directly views the other field. Lenses n some
valry may be seen f the different contours of the nstruments place the target fields at optical infin-
targets overlap, which is to be expected when dif- ty, but this s usually unnecessary unless there s
fering images are superimposed. The mages can a large esotropa. To help break suppression n
be made brighter by rnoving closer and reducing one field, light from a desk lamp can be directed
me background llumination. When suppression onto that field. Many other targets and stimulus
occurs, the patient blinks and moves the mirror variables are also available n the cheiroscopic
slightly to stimulate perception. Conditions can be training environment to make cheiroscopic games
ahered to make the task more difficult as progress s interesting and effective. Children usually enjoy
made; for example, the background llumination
358 Chapter12
this visin training technique (see the section able as there is no true sensory fusin of the dis-
Tracing for further discussion). similar images.
A cheiroscopic drawing variation is the circle
Counting and X technique. The therapist quickly draws cir-
This simultanelas perception technique requires cles on a paper in the dominant eye's field as the
the patient to hold the perception of various objects patient attempts to place an X in each in his or her
in the two fields at the same time. The types of suppressing field. The therapist's speed is governed
objects, real and drawn, are limited only by the by experience with the patient. The circle sizes are
therapist's imagination and the patient's interests. varied for the sake of challenge. At the end of this
Targets can be glued to paper, drawn, or held in speed task, the patient attempts to hold both tar-
place. At irst, the objects are counted, such as pen- gets and drawings in perception for 1 minute
nies, small seashells, or grains o sand. If the patient before suppression occurs. Blinking, flashing, and
is successful, the therapist asks him or her to retain intensity are variables readily available for antisup-
the images as long as possible as the patient counts pression purposes using this technique.
aloud rhythmically. Suppression is represented by
silence. Blinking, flashing, increased light, and Point-to-Point Chasing
movement actvate the suppressed image, at which Vodnoy8 reported a chas'mg technique that can be
point counting can continu. Therapist and patient easily performed on a cheiroscope. A pointer or
agree on a goal for the number of objects and time. pencil held by the therapist is slowly moved in
Once this goal is achieved, a new goal is chosen. the patient's dominant eye field. The patient holds
Counting can be challenging and fun. a pointer or pencil on the baseboard and posi-
tions the tip to superimpose it with the tip of the
Coloring and Drawing therapist's target. The patient attempts to keep the
The coloring and drawing variation of cheiroscopic tips superimposed as the therapist's target is
games is a fill-in task. A suitable une drawing atthe moved at increasingly faster rates. The therapist
patient's level of suppression serves to capture gauges the rate based on performance. The
interest. The patient uses colored pencils or cray- patient reports when suppression occurs. Antisup-
ons clued to the suppressing eye to color the draw- pression variables (e.g., blinking, flashing, and
ings. This first-degree fusin task requires that the illumination differential) are used as necessary.
patient only fill within the perceived Unes and not Point-to-point chas'mg requires active participa-
draw the contours of the target. The coloring will tion and usually captures a patient's interest (even
be at the subjective angle of directionalization; child patients).
it will appear in the same direction as the target
of regard. The therapist must emphasize clarity Tracing
of the target to control accommodation. Other- Cheiroscopic tracings can be an excellent anti-
wise, the coloring will appear to be moving because suppression exercise, both in and out of the
of the effect of variable accommodative conver- office. Simple cartoons or drawings are initially
gence. The crayon tip and the coloring will tend to used as targets for the dominant eye. More com-
be suppressed because they are clued to the non- plex designs can be included as the patient mas-
dominant eye. When suppression occurs, the ters this technique. The nondominant eye views a
crayon is jiggled to actvate perception of that blank, white sheet of paper and a pencil that is
image. The patient is instructed not to color the tar- held by the patient. The patient, having been
get unless the contours and the crayon tip are seen instructed to draw only when the Unes and the
at precisely the same time. As the patient exhibits pencil tip are seen at exactly the same time,
less suppression, the target contours are made attempts to trace the design seen in the mirror.
smaller and the selected crayon color should be The pencil tip and the line need to be viewed
less vivid (e.g., yellow or gray instead of red or simultaneously without altrnate suppression or
green). When a drawing is completed, the patient memory of the position. When the pencil tip dis-
should attempt to maintain the target and colored appears, the patient shakes it to break the sup-
rea in continuous perception for at least 1 minute. pression and then contines the tracing. If the line
Slight displacements of the two images are accept- disappears, illumination is increased for that eye.
Chapter12 359
one string is seen in ts entirety. An inadequate lose prisms or a prism bar. Sufficient prism is used
vergence response is indicated when there to join the double image of the fixated bead into
appears to be a double image of the fixated bead one as the technique requires.
or the string intersects either in front of or behind The use of string and beads is a simple and ver-
that bead. satile antisuppression technique suitable for home
Antisuppression stimuli for the string and beads training. Several vergence and oculomotor tech-
include blinking, flashing, movement of the string niques can be performed using the string and
(jiggling), and increasing illumination. The patient beads as a free-space control for suppression. The
can also wear red-green filters to introduce color patient can make near-far jump vergence move-
contrast to break suppression. One image of the ments from one bead to the next. Prisms can be
string should appear red and the other green. Inad- introduced for step vergences. The patient can also
equate vergence responses can be neutralized with build up gross convergence using the tromboning
Chapter12 361
televisin screen. Antisuppression variables that to the mirror so that both eyes can be seen (Figure
are readily applicable are blinking, rapidly flashing 12-10). The patient then moves the mirror away and
an eye (cover-uncover), moving toward the screen, tries to maintain sight of both eyes. Blinking, moving
and increasing contrast by dimming the back- the head, and increasing illumination are effective
ground room lights. As suppression is overeme at ways to break suppression when it occurs. The tech-
a near distance, the patient should take a step back nique is repeated with the patient trying to increase
from the televisin until suppression is seen again the fixation distance each time. The realistic goal is
and then should continu the training process. The for the patient to be able to see both eyes at a dis-
patient should always exert visual attention to tance of approximately 75 cm from the mirror, a
avoid suppression while watching a televisin pro- total of 1.5 m when looking in the mirror.
gram. Because this technique can be mentally
exhausting, frequent rest periods are advised. Reading Bars(T12.10)
When the technique is mastered, prisms can be
Reading bars were a popular antisuppression
used to introduce vergence demands. The televi-
method even in the time of Javal.1 The patient can
sin trainer in this case serves as a suppression
concntrate on any reading material that he or she
control for endpoint suppression.
chooses while working to break central suppres-
sion. This home training technique does require
Pola-Mirror(T12.9) sufficient motor fusin at reading distance before it
The Pola-Mirror10'11 can be used for visin training in can be used effectively. Reading bars, placed
heterophoric patients with central suppression. directly on the printed page, are available in polar-
Wearing polarized filters, the patient fixates an ized and red-green filter materials. Strips of filter
image of his or her face in a mirror. Each eye can see material are interspaced on transparent plstic and
only an image of its eye. Both eyes are visible under alternately clued to the eyes (see Figure 10-20).
binocular viewing conditions if there is no foveal The patient wears the appropriate filters over any
suppression. The filter before a suppressing eye needed refractive correction. Suppression will be
appears darkened, obscuring the image of that eye. recognized by the patient when a filter strip
The technique is for the patient to get cise enough appears dark, decreasing the visibility of print
Chapter 12 363
beneath t. The patient's task is to read across lines fusional vergence ranges, motor training is tempo-
of print or to look at pictures (for young children) rarily stopped f endpoint suppression is found; the
free of suppression for a certain length of time. suppression should be broken before continuing.
Often 10 minutes is required as a training interval. Therefore, antisuppression, sensory fusin, and
Suppression can be broken by blinking, flashing an motor fusin training consist of a reciprocally inter-
eye by occlusion, moving toward the book, or woven process. Antisuppression training builds sen-
increasing illumination. As suppression is over - sory and motor fusin; conversely, establishing
eme, the book and reading bar can be held far- good sensory and motor fusin prevents the recur-
Iher away from the patient to work on foveal rence of suppression.
suppression. When suppression s broken with an Suppression s deepest n cases of strabismus
ortho demand, flipper lenses and prisms often are with normal retinal correspondence, as it s the
assigned to expand accommodative and vergence only antidiplopic mechanism available. Because
skills while monitoring for endpoint suppression. the strength of the antisuppression stimulus must
ISee the section Bar Reading and Tracking [T10.23] match or exceed the depth and extent of the sup-
in Chapter 10 for further discussion of training with pression zone, in-office techniques that are unnat-
reading bars.) ural, such as the TBI (T12.1) and amblyoscope
training (T12.2), are appropriate and necessary
during the first phase of visin training. Effective
MANAGEMENT home training techniques include red filters
CONSIDERATIONS (T12.3) and hand-mirror superimposition (T12.4).
Antisuppression training also has the effect of Progression of targets is from peripheral to macular
building sensory and motor fusin. As suppression to foveal sizes with each technique. At some point
Aninishes, stereopsis and motor fusional ranges in the training, many patients begin to altrnate
usually ncrease. Antisuppression training naturally suppression, particularly with "fovea-sized" tar-
ewolves into sensory and motor fusin training. gets. Central suppression controls in each eye's
W hen the emphasis changes to the training of field of view are necessary.
364 Chapter12
Some ntermittent strabismic patients show eye. This usually breaks the suppression res-
good sensory fusin when the eyes are aligned but ponse, and vergence training can proceed (see
deep suppression when an eye deviates. It is Figure 12-6).
important for the patient to receive visual feed-
back of pathologic diplopia when the eye turns.
The break-and-join technique using the red lens CASE EXAMPLE
and filters (T12.3) is particularly effective in such
cases. However, if the ntermittent strabismus is Problem
associated with covarying ARC, the training objec- Trish, a 1 5-year-old straight-A student, presented
tive should be different. In these cases, there is for an eye examination without symptoms or a
usually little or no suppression; diplopia may not chief complaint.13 She had worn the following
occur even if suppression is broken, because of spectacle lenses for the previous 4 years: oculus
the ARC. A better strategy is to increase the dexter(OD), +2.50 -0.50 axis 010 (20/25~); ocu-
patient's fusional vergence reserves maximally to lus sinister (OS), +0.50 DS (20/20). The examina-
prevent loss of bifixation. tion revealed that she had 3 diopters of
Antisuppression training is an important step in the additional uncorrected axial anisometropia,
management of amblyopia, particularly anisome- intermittent central suppression, and reduced
tropic amblyopia. Holopigian et al.12 reported that stereopsis.
amblyopia and suppression often are inversely
related: The deeper the amblyopia, the less is the sup- Clmical Data
pression. Patients with shallow amblyopia often have The pertinent clinical findings are summarized as
deep suppression. Nevertheless, most cases of follows:
amblyopia require antisuppression therapy. Elimina-
tion of suppression is essential to prevent regression Keratometry
of amblyopia after visin therapy has been completed. OD: 42.75 @ 180, 44.00 @ 90
In cases of anisometropic amblyopia in which OS: 42.50 @ 180,43.25 @ 90
there is a potentia! for normal fusin, several anti- Retinoscopy
suppression techniques are particularly effective OD:+6.50-0.50 axis 180
to improve visual acuity. Three techniques are OS:+1.25-0.25 axis 180
discussed in Chapter 10 on amblyopia therapy: Turville infinity balance subjective
red filter and red print (T10.21); visual tracking OD: +6.25 -0.50 axis 157 (20/25)
with a stereoscope (TI 0.22); and bar reading OS: +1.00 DS (20/20)
and tracking (T10.23). Several techniques These refractive data were confirmed by cyclople-
described in this chapter are also appropriate gic examination using 1% cyclopentolate.
when acuity in the amblyopic eye has been Cover test with subjective therapy: orthophoria at 6
improved to 20/80 (6/24) or better. These include m and 5A exophoria at 40 cm
cheiroscopic games (T12.5); Brock string and Worth dot test with full spectacle correction: inter-
beads (T12.7); televisin trainers (TI2.8); and mittent central suppression of the right eye at
the Pola-Mirror (T12.9). all distances
Suppression is also a consideration in minimal Stereo Fly test with full correction in place: 200
binocular dysfunction cases of heterophoria, seconds of are
fusional vergence deficiency, and accommoda- Interna! and externa! ocular health was within nor-
tive deficiency. Very small fovea! suppression mal limits.
controls usually are necessary to identify sup-
pression if it exists. When training is given for
improved vergence ranges, foveal suppression Management
clues should be present for each eye so that altr- Although Trish was symptom-free, we expla'med to
nate suppression can be detected and broken if it her that her visual performance might increase if
occurs. Double pointing techniques are useful in she could adapt to the full anisometropic prescrip-
these cases, because they do not break motor tion and break the central suppression. Although
fusin. Using pointer sticks, the patient simulta- we thoroughly discussed the expected adaptive
neously touches the suppression control for each 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
Intial Examination 1 Mo 2 Mos 8 Mos
ropia with spectacle lenses, the patient n this case. Two years later, this patient was fitted
i pressed her willingness to wear the full prescrip- with rigid gas-permeable contact lenses and
! ton. Spectacle lenses were selected because adapted well to them without aniseikonic or other
the i ansometropia appeared to be axial rather symptoms.
than Iractive, judging from the keratometry
readings and, theoretically, should result n
relatively little aniseikonia. She was also nstructed REFERENCES
in the use of a polarized reading bar (T12.10) to 1. Revell MJ. Strabismus: A History ofOrthoptic Techniques.
break suppres-son and was assigned home London: Barrie & Jenkins; 1971:15,16-20.
training for 1 hour per day during her study 2. Bagolini B. Sensorial anomalies in strabismus. Doc Oph-
periods for 2 months' dura-fion. No other training thalmol. 1976;41:1-22.
3. Schor CM. Visual stimuli for strabismic suppression. Per
techniques were given. ception. 1977;6:583-593.
4. Jampolsky A. Characteristics of suppression in strabismus.
Arch Ophthalmol. 1955;54:683-696.
Results 5. Getz DJ. Strabismus and Amblyopia. Duncan, Okla.:
During the initial 3 days of wearing the prescribed Optometric Extensin Program; 1974;12:46.
lenses, Trish experienced minor headaches, occa- 6. Alien MJ. The Bartley phenomenon and visual rehabilita-
sional double visin, some spatial disorientation, tion: a home training technique. Optom Weekly.
1966;57:21-22.
and misjudgment of distances. Within a week, al I
7. Alien MJ. Shock treatment for visual rehabilitation. Opt J
adaptation symptoms disappeared, and the patient Rev Optom. 1969;106:616-624.
icported clearer visin and an ncreased sense of 8. Vodnoy BE. Orthoptics with the PSC Variable Prismatic
depth when viewing near objects. No suppression Mirror Stereoscope-Cheiroscope kit with correlary tech
was found at the 2-month progress check (Table niques. AmJ Optom. 1963;40:73-92.
12-5). Stereopsis had ncreased to 40 seconds of 9. Kramer ME. Clinical Orthoptics, 2nd ed. St. Louis: Mosby;
1953:161-163.
are, and good results persisted in later examina-
10. Griffin JR, Lee JM. The Polaroid-Mirror method. Optom
tions. It was noted that the stereopsis mproved as Weekly. 1971;61:29.
the suppression was eliminated. Eikonometer mea- 11. Griffin JR. Screening for anomalies of binocular visin by
surements indicated no aniseikonia. Trish rarely means of the Polaroid-Mirror method. Am ] Optom.
noticed diplopia, in spite of the induced prismatic 1971;48:689-692.
12. Holopigian K, Blake R, Greenwaid MJ. Clinical suppres
diference between the lenses when viewing was
sion and amblyopia. Invest Ophthalmol Vis Sci.
cfthe optical centers. Trish was very pleased with 1988;29:444-451.
her increased depth perception and visual skills. 13. Thal LS, Grisham JD. Correcting high anisometropia:
We believe that the antisuppression training was two case reports. Am J Optom Physiol Opt. 1976;53:85-
an important addition to the optical correction n 87.
diminating the obstacles to normal sensory fusin
chapter 13 / Vision Therapy for Eso Deviations
Many doctors prefer to manage esotropa either under the impression that fusional divergence
optically or surgically. These are often mportant ranges cannot be significantly ncreased. This
and necessary approaches in visin therapy, impression s incorrect, however; divergence
although sometimes the result is only cosmetic ranges and facility can be i ncreased.1~3 Similarly,
mprovement. Optical and surgical approaches do some clinicians prescribe prisms or lenses for
not exhaust the options available to the clinician symptomatic esophoric patients without thought of
who is dedicated to achieving a functional cure of including visin training. When patients are prop-
esotropa. Other than treatng amblyopia, visin erly selected, we have found visin training to be
training in cases of esotropa may not be a serious both an effective and practica! solution to treating
consideration for some clinicians, who may be both esophoric and esotropic deviations. When
368 Chapter13
have been partially or totally eliminated. Before prism segment over only the farpoint portion of the
sensory and motor fusin techniques are applied, lenses. Note that an overall BO compensating
the patient should be generally free of amblyopia, prism, although good at far, is contraindicated at
ARC, and deep suppression. (See Chapters 10, 11, near, because it would forc the DI patienfs eyes
and 12, respectively.) In some esotropes, the clini- to converge, as though he or she had convergence
cian may have to continu therapeutic regimens nsufficiency. Fusional convergence training is not
for these sensory anomalies while simultaneously advised n the initial stages of therapy; rather,
developing bifoveal fusin and improving motor fusional divergence ranges must be developed. As
fusional ranges. Also, before fusional divergence the magnitude and quality of sensory and motor
training begins, the doctor should ensure that basic fusin increases with visin training, the amountof
monocular skills (i.e., fixation, saccades, pursuits, compensating prism can be reduced considerably
and accommodation) are adequate for each eye. or removed entirely in some cases.
(See Chapter 2 for normative vales.) The strabis- A problem often arises with BO prism compen-
mic or amblyopic eye frequently demonstrates sation for esotropa if normal sensory fusin has
deficient ocular motility.4 If ocular motility is found not been established; in the latter case, the devia-
to be deficient, visin training usually is necessary tion usually will increase due to ARC or, possibly,
to develop these oculomotor skills before there is a suppresson.5 When prism adaptation s not a
concerted effort to increase fusional divergence. problem, BO compensation s an ideal way to
(See Chapter 16 regarding therapy for visin effi- maintain fusin. This, along with fusional diver-
ciency skills.) gence tranng, often allows for a gradual reduction
of the compensating prism power. In DI or BE
cases with prism adaptation, one alternatve during
Compensating Prisms and
a visin therapy program is to ncrease the prism
Lens Additions amount until adaptation ceases. Using Fresnel
If a residual eso deviation is present after full cor- prisms, it is possible to apply as much as 60A BO to
rection of the refractive error, the effect of compen- compnsate for an eso deviation. A greater amount
sating prisms or added plus at near needs to be of BO power can be obtained also by having prism
evaluated. If sensory fusin with optics can be ground into the spectacle lenses. The sum of that
achieved at some distance, open-environment additional prism and the Fresnel prisms allows for
training can be used, which provides the best prismatic compensation exceeding 60A. An alter-
chance for successful treatment. Normal retinal native is patching of an eye between visin train-
correspondence (NRC) must be present for prisms ing sessions to prevent ARC and suppression. If
and adds to be effective. When compensating sensory alignment of the eyes is not possible with
prisms and adds are prescribed, the patient should prisms and plus-lens additions at any viewing dis-
be checked frequently for the possibility of prism tance, the patient must wear a patch for a consid-
adaptation (see Chapter 6). erable amount of time while involved n visin
Although it s important to correct the full hyper- therapy.
opic refractive error in all cases of eso deviation, The CE esotropic patient benefits greatly from
plus-lens additions at near are not very effective in plus-lens additions, usually in the form of bifocal
cases of DI, because the AC/A ratio s low. How- spectacles or, possibly, contact lenses. Also, prism
ever, in some cases of basic esotropa, bifocal compensation may be needed for the far deviation
lenses may be recommended. The farpoint portion if it is significantly large. (The use of plus-lens addi-
of the spectacle lenses should not be overcorrected tions s also discussed in Chapter 7.) The minimal
with plus lenses, as blurred visin at far is unac- amount of plus power to achieve a sensory and
ceptable. An exception may be made in esotropic motor fusin response at near should be pre-
infants, because most of their visual requirements scribed, so that the patient can read and work at a
and interests are at near distances. In BE cases, BO comfortable viewing distance.
prism compensation may be necessary to keep the
patient fusing and, therefore, prevent the recur-
rence of amblyopia, ARC, or suppression. In cases Centration-Point Training
of DI, prisms usually are needed only for far visin. As part of esotropa management, Vodnoy6 high-
This can be accomplished by applying the Fresnel lighted the importance of findng a fixation ds-
370 Chapter13
Follow-Up Care
TABLE13-4. Vision Therapy
If a postoperative patient has used compensating
Sequence for Esophoria
prisms or plus-additon lenses to establish fusin
before the operation, it s important that new pre-
scription lenses be given to the patient immedi- 1. FuJI correctfon of any significant ametropia, partcu-
ately after surgery. It is hoped that the prisms and larly fatent hyperopa
lens additions will no longer be necessary. Fresnel 2, Prescription of eompensatory prisrn and added lens
Press-On prisms can be applied to new spectacle cofflblnations as needed
lenses as needed to resolve any significant diplopia 3, Training forgood monocular and binocuter fixation,
in the primary position or at the reading distante, saccades, pursuts, and accommodaton
but patching usually is not recommended. 4. Central sensorimotor fusin training to achieve
Vision training can be started again approxi- good stereopsls and mximum fusiona! vergence
mately 2 weeks after an operation. Immediately ranges free of suppression
postoperatively, the eye(s) are sensitive to irrita- 5, Developmerrt of good vergence faclty and stamna
tion and bright lights, so a little time off from 6. Maintenance of home exercises and periodic
training s appropriate. If preoperative visin progress checkups
training and the operation have been successful,
the patient quickly establishes fusin in the open
environment, and the angle of deviation rapidly for esophoria s outlined n Table 13-4. This
stabilizes during the healing process. Vision sequence parallels that for esotropa but excludes
training s directed toward identifying and break- management of major sensory conditions; n addi-
ing any suppression that may occur. Motor fusin tion, surgery s not often necessary. The emphasis
ranges and vergence facility are again maximally s on breaking foveal suppression and building the
ncreased. If there is any restriction of ocular quantity and quality of fusional vergence.
motility in some fields of gaze, training might In DI esophoric cases in which the deviation s
help to reduce the restrictions. In all cases, greater at far, push-away and walk-away training is
whether postsurgical or not, when vergence skills provided. Examples include the Brock string and
are maximally ncreased, retainer exercises are beads (T13.6), Vectograms and Tranaglyphs (T13.9),
given to the patient and a regular recall schedule penlight and anaglyphic filters (T12.3), Pola-Mirror
is established on the basis of quality of results. (T12.9), and televisin trainer (T12.8). Vision train-
ing from near to far also applies to BE cases, even
though the eso at near and that at far are of
VISION THERAPY SEQUENCE approximately the same magnitude. As discussed
FOR ESOPHORIA previously, the fusin "glue" s stronger at near
than at far, thereby allowing a patient to achieve
Most cases of esophoria and intermittent esotro-
the easier tasks initially before he or she attempts
pa can be successfully managed with some
the more difficult tasks at far. Failure at far is likely
combination of prisms, added lenses, and visin
without prior training at near. Failure should be
training. Surgery also may be required but s not
avoided and success should always be emphasized
frequently necessary. In our experience, a home
in visin therapy. In CE cases in which the devia-
visin training program of 20-30 minutes per day
tion is greater at near, a push-up technique can be
for 8-12 weeks (with weekly office visits) usually
assigned, using instruments as mentioned for cases
is sufficient to elimnate symptoms and meet
of DI esophoria.
relase critera. If the patient s not making ade-
quate progress n a home-based program, an n-
office training program including two or three
visits per week may be necessary for successful SPECIFIC TRAINING TECHNIQUES
treatment. Sixteen exemplary visin training techniques that
Therapy for esophoria is a continuaron of that are particularly appropriate for cases of eso devia-
for esotropa n that t s a contnuing process to tions are presented. Numerous other effective tech-
achieve clear, single, comfortable, efficient binoc- niques are available for use by clinicians, and
ular visin. A general sequence of visin therapy many doctors and therapists improvise techniques
374 Chapter13
based on their experience in treating patients. The tor must use the unilateral cover test to monitor
techniques we present here generally follow a bifoveal alignment; this breaks fusin if it has been
sequence from treating the most difficult cases, as achieved. The patient should be encouraged to
in esotropa with poor sensory and motor fusin, to rejoin the images after the cover test as a break-
treating the least difficult cases, as n esophoria and-join training technique. Other techniques
with relatively minor deficiencies of sensory and (e.g., Mirror Stereoscope [T13.2], Vectograms and
motor fusin. Another way to look at this sequence Tranaglyphs [T13.8]) can similarly be used for iso-
is to consider the first techniques in the series as metric exercises to transfer to the open environ-
relatively easy for the patient to master. The clini- ment the learned skill of fusional divergence n the
cian should always be flexible, however, and major amblyoscope.
choose those techniques that are most appropriate
for the particular skill and interest level of each Bernell Mirror Stereoscope
patient.
Base-ln Training (T13.2)
The Mirror Stereoscope from Bernell Corporation
Amblyoscopic Divergence is a Wheatstone Stereoscope (Figures 13-1 and
Technique(T13.1) 13-2). The nstrument includes two mirrors
The amblyoscopic divergence technique discussed mounted on arms that are shaped n the form of
here s similar to that presented in Chapter 11 for the letter W: henee its colloquial clinical ame,
esotropa with ARC (T11.7). However, the emphasis Flying W. Prismatic changes are made by varying
here s on improvement of the fusional divergence the angle between the mirrors. A range of 40 A Bl
range n the nstrument, the assumption being that to 50A BO can be made by simply adjusting the
NRC s present. This technique usually is applied n angle of the nstrument. This large range makes
cases of esotropa but can also be used for esopho- the Mirror Stereoscope particularly useful n
ria when lttle or no progress has been made usng cases of strabismus. For measurement purposes,
other techniques. Large stereoscopic targets with a scale calibrated n prism diopters s placed at
suppression controls are used (e.g., the swing si des; the appropriate place according to nstructions
see Figure 11-5). Rapid altrnate flashing intensifies accompanying the nstrument.
the perception of stereopsis and breaks suppression BO is induced by narrowing the angle of the
that may be present. With the targets initially set at nstrument (narrow W), whereas Bl demand s cre-
the subjective angle, the amblyoscope arms are ated by widening the nstrument's angle (wide W).
diverged slowly until the images become diplopic The fixation distance from each eye via the mirror
or suppression occurs. The divergence demand then to the target s approximately 0.33 m; therefore,
s reduced just enough for the patient to re-establish optical infinity can be created by using plus lenses
fusin. This vergence demand s held stationary for of approximately 3.00 D. The plus addition can
1 or 2 minutes as an isometric exercise. The take the form of trial lenses worn over the cor-
amblyoscope arms then are diverged slowly again, rected ametropia most plus (CAMP) lenses. Train-
and the technique s repeated until mximum diver- ing at optical infinity s an important goal n cases
gence has been achieved within a 20-minute of DI and BE esotropa. Plus-addtion lenses usu-
period. ally are not needed n cases of CE esotropa unless
The emphasis in this training technique s to the nearpoint deviation s beyond the BO scale of
expand the divergence range within the nstrument the i nstrument.
and then to have the patient view distant objects n The initial phase of this technique s devoted to
the open environment while he or she tries to helping the patient to achieve fusin at some ver-
maintain the achieved divergence. In cases of gence demand, possibly BO if necessary. Targets
esotropa, partial prism compensation usually is with the appropriate level of difficulty are placed
necessary to help the patient maintain binocular n the target holders and can be aligned at the
algnment n the open environment. Besides seeing patient's subjective angle of deviation. Some of the
diplopically for feedback when motor fusin is fusin targets have large suppression controls,
lost, the patient also uses the sensation of eyestrain which is important in cases of deep suppression.
to provide subjective feedback that free-space An auxiliary light source (e.g., a desk lamp) can be
motor fusin is occurring. At some point, the doc- shined directly onto the target of the suppressed
Chapter 13 375
MIRRORS O.S. a.
TARGET //' O.D. TARGET
b.
sliding vergence ranges from a 10 A BO to 10A Bl
b.
range around the angle of deviation, not necessar-
ly clearing the ortho setting of the nstrument. Ver-
gence training s performed in both horizontal
directions, with an emphasis toward the Bl direc-
tion. An ideal goal would be to increase vergence
ranges (e.g., blurpoint, breakpoint, and recovery) to
conform to the normative nearpoint vales Usted in
Chapter 2. Training can be accomplished either in
the office or at home. The typical training period for
this technique is 10 minutes per session of continu-
ous activity of moving the targets between the lim-
its of convergence and divergence. The patient's
goal at this point is to increase vergence ranges, not
speed, while maintaining clear, single, suppression-
free binocular visin.
Brewster Stereoscope
Base-ln Training
The refracting type of Stereoscope was invented by
Brewster a decade after the first Wheatstone (mirror)
FIGURE 13-1Bernell Mirror Stereoscope. a. Front view. b. Back Stereoscope was devised. Unlike the Wheatstone
view. c. Adaptation as a cheiroscope for antisuppression therapy.
d. Wheatstone type of Stereoscope for prismatic variation for first -,
second-, and third-degree fusin demands. (O.D. = oculus dexter;
O.S. = oculus sinister.)
separation of 87 mm represents 4A BO and s the sis while suppression s being monitored. Ini-
practical distance that compnsales an eso pos- tially, the homologous points may need to be
tural shift caused by the proximal convergence. For relatively cise together to crate a BO compen-
this reason, stereograms designed for an ortho sation for the esotropic or esophoric patient. For
demand have homologous point separations of example, the separation of the targets could be
approximately 87 mm. 77 mm to help the patient fuse, by providing a 5 A
Note that standard Brewster stereoscopes have BO compensation ([87-77]/2 = 5) for the eso
an optical-center separation distance of 95 mm, deviation. The patient can maintain fusin on a
and the 87-mm homologous point separation target with a divergence demand for a designated
applies. (Some small stereoscopes vary in this stan- time (e.g., 1-2 minutes) as an isometric exercise.
dard, so the doctor should measure the optical- When there s good fusin, the target separation
center separation if in doubt.) can be increased to, say, 87 mm for an ortho
When nearpoint training (closer than optical demand. Over time, the patient should attempt to
nfinity) is performed in a Brewster stereoscope, fuse the targets when the separation becomes
new target separation vales represent the ortho wider, thus creating Bl demands to stimulate
demand setting of this instrument. A nearpoint fusional divergence.
accommodative stimulus of 2.50 D s represented The next phase of training with the stereoscope
by a distance of 0.133 m (13.3 cm) within the col- is to introduce vergence steps. Figure 13-5 depicts
lapsed optical space of the stereoscope. The 0.133- a typical stereogram providing step vergence
m distance has a dioptric valu of 7.50 and, demands. The top pair of targets has a relatively
because the 0.2-m distance has a dioptric valu of more Bl demand than does the bottom pair. Later
5.00 D, the total demand on accommodation is in training, as the patient's fusional divergence
7.50 - 5.00 = 2.50 D. The h valus calculated for ability improves, BO demands are placed on the
nearpoint as follows: bottom and relatively large Bl demands are posi-
tioned on the top of the stereogram. This s training
h = 95x0.133x5 = 63 mm vergence facility, also known as vergence rock. It is
phasic (fast) vergence training, as opposed to the
This means that f the homologous points are sepa- initially easier technique for steady isometric ver-
rated by a distance of 63 mm, the vergence gence training. (See Chapter 2 for goals for fusional
demand at this nearpoint distance of 0.133 m is vergence ranges and facility.)
ortho. At this particular distance of 0.133 m (1.33 If there is suppression, an external light source
decimeters), it takes 1.33 mm of lateral displace- can be directed toward the suppressed image; also,
ment on a stereogram to equal 1A. For example, if bimanual pointing can be added to break the sup-
the circle and star are 59 mm apart, the BO pression response (see Figure 12-6). Corporations,
demand s 3A (4/1.33). At the farpoint (2 decime- such as Keystone View, Bernell, and other suppli-
ters), every 2 mm on the stereogram equals 1A, and ers, provide a large variety of stereograms designed
every 1.33 mm equals 1A at the nearpoint (tradi- for most levis of sensory and motor ski 11 and dif-
tionally at 2.50-D demand with a fixation distance ferent interests of patients. Examples of stereo-
of 1.33 decimeters). Any prismatic demand can be grams designed specifically for young children are
determined by applying this "decimeter rule" when the Dvorine Cards (Figure 13-6). Stereograms
stereograms are used in a Brewster stereoscope. appropriate for older children and adults include
the Biopter Bl and BO Cards (Figure 13-7). In addi-
Isometric and Step Vergences (T13.3) tion, the Bl range of the Brewster stereoscope
One of the most widely used Brewster stereo- exceeds its BO range, making it an ideal instru-
scopes s the Keystone Telebinocular (see Figure ment for building divergence abilities. This point is
13-4). The Biopter and the BernelI-O-Scope are made explicit in the following discussion of the
two of the many examples of small Brewster ste- tromboning technique.
reoscopes for home training purposes. Many train-
ing techniques can be performed with such Stereoscope Trombonng (T13.4)
nstruments. Although some stereograms are split to allow for
The first phase of training involves having the sliding vergence training with Brewster stereo-
patient fuse a stereogram and appreciate stereop- scopes, stereogram sliding s more easily accom-
378 Chapter13
plished with mirror stereoscopes that provide fact has mplications for training provided for eso
gradual changes n BO and Bl prismatic demands. deviations. Most stereogram targets have a fixed
However, the Brewster stereoscope s uniquely target separation so that when they are slowly
designed for the application of tromboning ver- tromboned closer to the patient on the instrument,
gence training. Donder's line n the Brewster ste- the vergence demand becomes progressively more
reoscope s represented at near accommodative divergent. Even if the stereogram vergence demand
demands by decreasing target separation dis- at optical infinity s convergent, as the target is
tromboned to nearpoint distances the convergent
demand decreases; at some point along the
accommodative scale, there is a Bl demand. Trom-
boning on this nstrument, therefore, increases the
stimulus to accommodation and divergence simul-
taneously. The beneficial effect of this "shaking-up"
technique is that the patient learns to dissociate
accommodation from convergence in this para-
doxical process of diverging while focusing at
near.
Because of this optical relationship, almost any
stereogram can be used to expand the range of
fusional divergence with tromboning. In the case
of esotropa, BO cards (e.g., the Dvorine Cards)
FIGURE 13-6Example of a Dvorine with appropriate target separation can be selected
stereogram (Keystone View, Divisin
so that the patient can fuse them easily. As the tar-
of Mast/Keystone).
get is slowly moved closer, the patient consciously
tances. At far (optical infinity),
attempts to maintain fusin and stops the trombn-
the target separation for
ortho demand (distance
between homologous points
for no vergence demand) is 87 mm; at the
equivalent of 40 cm, t s 63 mm; and at closer dis-
tances, the target separation of ortho demand is
progressively smaller (Figure 13-8). This optical
ChapteMB 379
FIGURE 13-7Example of a
Biopter stereogram (Stereo Optical
Co.).
ng momentarily when suppression or diplopia fusin skills. This technique can be applied in
occurs. The position of the stereogram on the cases of amblyopia if the acuity s at least 20/80 in
accommodative scale s noted; on subsequent tri- the affected eye.
is, the patient attempts to ncrease the range of The first step, as usual, is full correction of any
fusin. The therapeutic goal during a 10-minute significant refractive error. Next, the strabismic
training interval s to ncrease the range of deviation s neutralized with Fresnel prisms or a
response but not necessarily the speed of response. centration-point add at the child's nearpoint
Speed of tromboning can be ntroduced as a goal working distance for this game. Prism power s
after the patient's fusional range has been maxi- i ncreased as needed if there s prism adaptation
mally expanded. (as discussed in Chapter 6). The parent s given or
In esophoric cases, Bl stereograms (e.g., Bl
Biopter Cards) may be fusible for the patient and FIGURE 13-8Decreasing target separation for ortho demand for ste-
reograms in a Brewster stereoscope as fixation distance is decreased.
can be ntroduced from the outset. As these cards
are tromboned closer along the accommodative Far (optical infinity)
acquires the foilowing tems: (1) 1 square yard of Brock String and BeadsBase-ln
black felt material; (2) red-green plstic filter Training (T13.6)
spectacles with an elastic band; and (3) at least Breaking suppression and establishing physiologic
30 small plstic toys of various sizes in three col- diplopia with the Brock string and beads (see Fig-
orsred, green, and yellow. We have used small ure 12-7) has been previously discussed (T12.7);
cars, animis, Lego blocks, pegs, and beads, all of however, this technique can also be used for
which can usually be found in abundance at most fusional divergence training. Bl training to build
toy stores. The red and green toys must appear as fusional divergence ranges and reflexes in the
black when viewed through the opposite filter open environment can be accomplished effec-
(i.e., mutual exclusin). Also, the yellow toys tively at home or in the office in selected cases of
should appear red through the red filter and green esotropa and esophoria. In esotropa, the first step
when viewed with only the green filter. s to provide the patient the opportunity for sensory
The anaglyphic game proceeds as follows: fusin by using prsms or a centration-point add.
Wearing the prism glasses and red-green filters, One bead is placed at the ortho demand setting
the child sits on the piece of black felt placed on along the string, and a second bead is positioned
the floor. The toys are strewn randomly on the to crate a small fusional divergence demand (e.g.,
felt in front of the child. The child's task is to find second bead behind the first bead in cases of DI).
and seprate the toys into three piles on the The patient attempts jump vergences between the
basis of their colorred, green, or yellow. The two beads and tries to perceive physiologic diplo-
yellow toys will be seen as yellow (or some pia with each fixation. Any suppression that occurs
color different from the others) only if there is may be broken by blinking an eye or by movement
sensory and motor fusin at the moment of of the string; suppression should be broken before
selection. If the child suppresses or sees double, the technique is continued. The technique is timed
the yellow toys will appear to the child as either for a selected number of cycles for each set. With
red or green and will, therefore, be placed in the training, the speed and amplitude of the jumps are
wrong pile. At the end of the game, the child increased maximally.
and trainer look at the piles without the red - In cases of basic esotropa or esophoria, a step
green filters to check successes and errors. vergence variation of this technique is more effec-
Depending on the child's wishes, the parent tive than are jump vergences. Step vergences, par-
might like to develop a reward system (e.g., ver- ticularly those emphasizing Bl demands, are
bal praise, stickers, or stars) to reinforce partici- introduced with either flipper prisms or lose
pation or success in the game. prisms. It is important to begin with reasonably
The difficulty level of the game and the sen- small vergence stimuli so that the patient does not
sory and motor fusin stimuli can be changed to struggle excessively during this training. The patient
meet the needs of each child. When deep sup- sequentially fixates each of three beads placed
pression occurs, large colored toys and high along the string at prescribed training distances.
background illumination are provided. With Physiologic diplopia is established and maintained
shallow suppression, a lot of small colored pegs by antisuppression techniques during the entire
or beads can be used. Motor fusin demands exercise (see the section on T12.7 in Chapter 12).
can be increased by reducing the amount of Working for speed, the patient completes 60 cycles
Fresnel prism compensation or by introducing of step vergence on each bead while making note
flipper lenses or prisms that demand fusional of physiologic diplopia. The time is recorded for the
vergence. The child's success rate in the game entire sequence. The fixation distance is gradually
provides a check on the level of fusin skill the increased, and distances between the beads are
child is developing. In our experience, for opti- increased as training proceeds.
mum training results, the child should correctly
select the yellow toys at least 70% of the time
but not consistently 100% of the time. If the Peripheral Fusin RingsBase-ln
child's success rate is less than 70%, he or she is Training at Far (T13.7)
likely to become frustrated, whereas 100% suc- There are severa! good peripheral stereopsis
cess usually means that the game is too easy to devices for enhancement of fusional divergence
have training valu. at far. An example is the design of Root Rings
Chapter13 381
a. e. h.
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
vergence skills can then be ncreased with sliding, Mother Goose Vectogram (see Figure 13-11 e) s
step, jump, tromboning, and isometric vergence particularly helpful for children at this basic level
training techniques. of training, because it has large suppression con-
In cases of esotropa and esophoria, the trols for all three figures. As each figure is fused in
emphasis is on developing and expanding sup- turn (each having slightly different step vergence
pression-free, fusional divergence ranges and step demands), suppression may be broken by blinking,
divergence reflexes that are fast and accurate. reduction of the overall vergence demand, or
Some valuable attributes of the Vectograms are pointing with a stick. As the patient contines mak-
their variety and flexibility. They can be used with ing the small step vergence movements from one
many types of patients (strabismic and phoric, figure to the next, the slides are separated slowly in
either eso and exo) n many ways and at various the Bl direction. The patient uses mental effort to
viewing distances. Because of their expense and keep the images fused and free of suppression.
vulnerability to damage, most visin therapists Sliding vergence ranges are trained in both Bl and
use them for in-office training. Split Minivecto- BO directions, alternating from one limit to the
grams (horizontal and vertical) are also available other but emphasizing the divergence range two-
for home training purposes. thirds of the time. Training in both horizontal
Tranaglyphs are sets of translucent vergence directions ensures that the zone of clear, single
training slides, printed n red and green, and used binocular visin is expanded and not merely
in a similar manner as with Vectograms. The shifted in the Bl direction. When diplopia occurs,
patient wears red-green filters to achieve mutual the demand is reduced sufficiently to allow recov-
exclusin of the images. Because of the white illu- ery of fusin; the patient contines making small
minated background, the red-filtered eye sees only step vergence movements for a minute or more
the green target, and the green-filtered eye sees before the divergence demand s again ncreased.
only the red target. There are several available Smoothness of disparation with lack of suppression
Tranaglyph si de sets, of the variable (500 [see Fig- is an important goal, as is expanding the vergence
ure 13-10] and 600 series) or nonvariable (50 ranges. The patient notes each blurpoint (if any s
series) type. There is even a set devoted to training perceived), breakpoint, and recovery point in each
vertical vergence (the 70 series). direction and records the highest vales during the
Tranaglyphs are used n free space, as are Vecto- training interval of approximately 10 minutes. Split
grams, but the stereopsis conten of the slides tends Tranaglyphs are used n a similar manner.
to be less vivid. The advantage of Tranaglyphs over When progress has been made with the Mother
Vectograms s that they are relatively inexpensive Goose slide, increased sensory fusin demands
and more durable, and the subject matter seems to can be ntroduced with the Spirangle Vectogram
be more motivating for teenagers and adults (e.g., (see Figure 13-11b). This spI t Vectogram contains
sports action pictures). Also, head or target tilting is subtle stereopsis and suppression clues that chal-
not problematic, as t can be for polarizing devices lenge most patients. The goal is to achieve a nor-
(Le., polarizaron effect lostwith significant tilting). mal range of fusional convergence and divergence
Tranaglyphs can be placed n a hand-held slide that s free of suppression.
holder or in a Dual Polachrome Illuminated Later in the training program, other spiit Vecto-
Trainer. Most slides have adequate suppression grams can be added (e.g., using the Dual Pola-
controls for each eye. chrome Illuminated Trainer). The top target is set at
the patient's mximum limit of fusional divergence
Divergence Training at Near (T3.8) (i.e., ciear and single), and the bottom target is set
If an esotropic patient has NRC, spiit Vectograms at the fusional convergence limit. The patient then
and Tranaglyphs are placed at the angle of devia- is instructed to fixate rapidly from one Vectogram
tion (the objective and subjective angles being the to the other, f using each n turn to train the speed
same) n an attempt to establish sensory fusin at of step vergences (i.e., vergence facility).
40 cm. At this distance, the vergence scale on the Step vergences can also be trained using the 50
slides reads directly in prism diopters. On aVecto- series of nonvariable Tranaglyphs. This series of
gram, the numbers represent BO demands and the sports action figures has a different vergence
letters, Bl demands. An add or prisms can be worn demand for each figure. The first card n the series
f the size of the nearpoint deviation s large. The consists of four figures having the following
384 Chapter13
P^Wr \^5 5^
demands: 1A Bl, 1A BO, 2A BO, and 4A BO. The has been reached when the patient can make steps
other figures in the series increase in vergence from a large BO demand to his or her mximum Bl
demand by 2A steps to a mximum of 30A (see Fig- demand, with good facility and without suppres-
ure 13-10). Convergence demands can be sion. This phasic vergence training technique is
switched to divergence demands by simply turning particularly effective, as the targets have stereopsis
the rigid vinyl card over or by reversing the left- content and good suppression controls.
right placement of the red and green filters worn
by the patient. Also, flipper prisms can be used for Divergence Walk-Aways (T13.9)
step vergence training (Figure 13-12). Split Vectograms and Tranaglyphs are particularly
For either an esotropic or esophoric patient, the helpful for DI and BE patients who lose fusin
therapist selects a BO demand target that can be often as the fixation distance is increased. A good
easily fused. A second target with less BO demand pair of targets is the Spirangle Vectogram, which is
is set in the holder above the first target. The large and has an appreciable stereopsis effect at far
patient altrnales fixation between the two targets distances (see Figure 13-11b). The Bl demand
as quickly as possible, fusing each in turn, while should be increased maximally at near while the
monitoring for suppression. If suppression occurs, patient maintains fusin. As the patient slowly
the patient should break it by blinking or moving walks away, the spiral figure appears more in depth
closer to the targets. The patient is instructed to and the Bl demand decreases (theoretically),
count the number of fixation cycles. Twenty cycles which should make fusin easier for the patient.
often are prescribed, and the patient attempts to For example, 12A Bl at 40 cm transales to only 6A
better his or her time with each set. The therapist Bl at 80 cm and only 3A at 160 cm, and so on (Fig-
prescribes as many sets as the patient can com- ure 13-13). Patients are delighted to realize that
plete within a 10-minute training session. The size they can fuse at far; this builds confidence and
of the vergence steps can be increased as the motivation. Once the patient is fusing at far, the
patient's proficiency improves. The last stage of spiit targets are separated further (sliding vergence)
training with vectographic or tranaglyphic targets to increase fusional divergence skill.
Chapter 13 385
Vectogram
O
\
\
40 cm \
\
80 cm
160cm
Projected Base-ln Sudes (T13.10) aligned nitially to the patient's subjective angle of
Using an overhead projector, the therapist can devation, a BO setting. This technique s ideal for
project spiit Vectograms onto a special screen for training sliding vergences at far, due to the fusional
fusional vergence training. The images must fall on "lock" of stereopsis. Besides sliding vergence, step
a metallic surface (or special vinyl material) so that (using two pairs of targets at the same distance)
the polarization qualities are not lost. The patient and jump (altrnate near-far viewing) vergence
wears crossed polarizing filters as the target sepa- training can be used to build the range and facility
ration s ncreased in the Bl direction. In esotropa, of fusional divergence.
particularly the DI and BE types, the targets are Tranaglyphic projection may be a more practical
choice for some visin therapists, as they are printed
in red and green and do not require any special sur-
386 Chapter13
face for projection other than a blank wall. The Ber- achieve at least 10 cycles per minute. We have
neli 500 or 600Tranaglyph Kits are good choices for found these training goals to be realistic expecta-
this technique. These split tranaglyphic techniques tions and effective in preventing regression of ver-
are carried out in the same manner as are those in gence skills. Binocular accommodative rock is
which split Vectograms are used. easily combined with other vergence training
techniques, such as with Vectograms (TI3.8),
Brock string and beads (T13.6), or the Aperture-
Binocular Accommodative
RuleTrainer(T13.13).
Rock (T13.11)
Monocular accommodative skills should be
ensured before binocular accommodative training Vergence Rock Techniques
is given (see Chapter 16). Binocular accommoda- (Flipper Prisms)(T13.12)
tive rock can be used to increase accommodative Flipper prisms or lose prisms are effective for
and vergence skills, particularly in esophoric training step vergences at far or near either in the
patients (see discussion in Chapter 2). Patients with office or at home (see Figure 13-12). If the eso
basic esophoria or CE generally have difficulty patient initially is unable to fuse when a Bl
clearing the target when looking through minus demand is introduced, BO prism compensation
lenses. Binocular facility is poor due to a limited may be necessary until divergence ranges are
range of fusional divergence (i.e., the eso deviation developed to meet step (phasic) demands. The
increases with the accommodative stimulus, and important rule to remember in visin training is
the patient must rely on fusional divergence to that the demand must be within the patient's
maintain single and clear binocular visin). capability; the demand is increased only as the
The therapist should start this technique with patient's ability increases. Likewise, as the step
small amounts of minus lens power (i.e., -0.50 D vergence range increases, the power difference in
to -1.00 D). The amount is determined empirically BO and Bl flipper prisms can be increased. Speed
by working with the patient. Equal plus and minus and range of vergence facility then are trained.
flipper lens powers are commercially available, or The goal is vergence facility and stamina that at
the therapist can prepare unequal powers as least meet the criteria presented in Chapter 2 (5
needed using a clip demonstrator lens holder and cycles per minute with 8A Bl to 8A BO at near and
trial-case lenses. The nearpoint target should have 4A Bl to 8A BO at far). Vergence rock can often be
suppression controls appropriate for the patient's combined with other training techniques, such as
level of sensory fusin. Various targets can be used Brock string and beads (T13.6), peripheral fusin
for this purpose (e.g., strip reading bars, Minivec- rings (T13.7), and Vectograms or Tranaglyphs
tograms, and Minitranaglyphs; see Figure 16-6). (T13.8-T13.10).
The technique requires the patient to flip the Bar reading (T12.10) with prism rock is a
lenses (keeping them horizontally aligned with the demanding exercise that is often given in the final
eyes), fuse and clear the target, note the suppres- stages of training and as a retainer exercise. A
sion controls, and build the speed of alternation. lose prism of low power is held by the patient,
The lenses are not flipped until the target is per- using the thumb and ndex finger to grasp the bot-
fectly clear and the suppression controls are tom of it. With the bar strips placed vertical ly
present. The patient or therapist records the num- over the reading material and the prism held
ber of cycles within a prescribed time interval (1- before one eye, the patient reads across the line,
2 minutes) or the amount of time required for a noting any suppression and trying to break it by
patient to complete an assigned number of cycles. blinking. After reading each line, the patient shifts
These numbers are logged to chart progress. With the prism to the other eye with one quick move-
short rest periods of approximately 30 seconds ment of the hand. The prism, therefore, changes
between sets, the patient contines this exercise direction from Bl to BO. Reading in this manner is
for a 10-minute period each day until proficiency continued for a 10-minute period. With practice,
is achieved. For nonpresbyopic adults, the binocu- patients can learn to read passages for meaning
lar flipper rate should eventually be 20 cycles per without thinking about sensory or motor fusin.
minute using +1.50-D flippers. Using +2.00-D The prism amount can be increased each week as
flippers, children aged 8 years and older should needed.
Chapter13 387
locationsup, down, left, or right. The patient "nonaccommodative" type of CE was reported by
must fuse the target to indcate the correct position von Noorden and Avilla.11 In their series, there
of the stereoscopic mage using a joystick. Smooth was a larger esotropa at near as compared with
disparation of the targets (sliding vergence) s pos- far, but plus-addition lenses did not reduce the
sible at various speeds or in steps of various magni- nearpoint deviation as would be expected in the
tudes to build vergence ranges. Children and case of a high AC/A ratio. These researchers pro-
adults appreciate the game features of this pro- posed that increased tonic vergence somehow
gram. We recommend such computerized pro- resulted in the larger deviation at near. The gradi-
grams because ' of the patient interest and ent AC/A ratio proved to be low or normal.
motivation they stimulate. Several suppliers offer Although a patient with this nonaccommodative
visin therapy software. type of CE esotropa does not benefit from wear-
Computer Orthoptics by Dr. Cooper (see Appen- ng bifocals, the condition can be successfully
dix J) introduced a computer program combined managed in many cases with visin training and
with high-speed liquid crystal filters for mutual strabismus surgery.
cancellation of targets for the right and left eye. For In contrast, most patients having a high AC/A
use of this program, the patient wears gray liquid type of CE show esotropa at near that can usually
crystal filters instead of red and blue filters. These be treated successfully with lenses. Our visin
filters alternately darken at 60 Hz, allowing for sta- therapy approach involves fully correcting the
bilized binocular viewing. High resolution and refractive error, prescribing appropriate bifocals to
color stimuli can be presented. Our patients report control the near deviation, and initiating a vigor-
being aware, however, of a flickering background, ous visin training program. Amblyopia and ARC
but usually this is not significantly annoying. usually do not develop in CE patients who main-
Major et al.2 found that Bl ranges could be sig- tain fusin at far. For this reason among others,
nificantly mproved by using computerized tonic these patients generally have a better prognosis
and isometric divergence demands. The computer than do BE esotropes who tend to have a constant
as a visin therapy too! s a welcome develop- deviation at far.
ment, as it can ease the labor-intensive in-office The effect of plus-addition lenses can be
practice of visin therapy and make such therapy remarkable in cases of CE, because the AC/A
more affordable to patients than in the past. Many ratio is high. For example, a patient with a 60-
of the techniques discussed earlier n this chapter mm IPD with 6 A of esotropa at 6 m and 16 A at
can be applied with computerized programs for 40 cm has a calculated AC/A ratio of 10/1 and
mproving fusional divergence ranges, facility, and probably a gradient AC/A ratio of 7/1 or 8/1.
stamina. Software for home training s also avail- (Refer to Chapter 3.) This high ratio mplies that
able. (See Chapter 16 for further discussion of for every diopter of plus-lens additon that s
computerized visin therapy.) worn, the eso deviaton s reduced by at least 7 A
or 8A. Therefore, a +1.00-D additon would cause
the deviaton at near to be reduced to approxi-
CASE MANAGEMENT mately 9 A eso, whereas a +2.00-D addition
AND EXAMPLES would reduce the deviation at near to approxi-
mately 2 A eso. These are theoretcal vales, as
Convergence Excess Esotropa the esotropic patient does not always respond to
Management Principies the plus additions mechanstically. The clinician
CE esotropa and esophoria are characterized by must directly observe and measure how the
a near deviation that is substantially larger than at patient responds to plus-addition lenses at near
far. If the patient s phoric or ntermittently stra- before a lens prescription is written.
bismic at near, visual symptoms when reading We recommend wide, flat-top segments, 28 to
may be reported (e.g., intermittent blur, diplopia, 35 mm, that give good optics for near work. Cal-
and asthenopia). Many CE patients have consider- oroso and Rouse12 recommended that the top of
able suppression at near; therefore, symptoms the bifocal segment be placed at midpupil for chil-
such as diplopia do not always result.10 CE usually dren younger than 5 years, because children tend
is caused by an abnormally high AC/A ratio with to look over the top of the segments. For children
inadequate fusional divergence. However, a aged 5-8 years, the top should be at the lower
392 Chapter13
rnargin of the pupil and, for older patients, the seg- In most cases of CE in which fusin can be
ment height would be at the lower eyelid margin. established with bifocals at some near distance,
These investigators also advocated progressive completion of visin training usually takes from 2
addition lenses for the sake of cosmesis and for to 4 months. These cases can often be managed
promoting fusin at intermedate distances. The on a home training basis supplemented by weekly
top of the progressive addition lens segment office testing and training visits. A good retainer
should be placed 4 mm above the center of the exercise s bar reading with prism (T13.12), as t
pupil for children younger than 8 years and 2 mm monitors for suppression and trains the reflex
above for older patients. aspects of fusional vergence. Bar reading with
In cases of accommodative esotropa, espe- prism for 15-20 minutes once weekly is usually
cially CE cases, there s usually the need for active sufficient to prevent regression of trained binocu-
visin therapy to break suppression and build ver- lar skills.
gence ranges and facility. Bifocals correct only the
nearpoint deviation in CE at one particular view-
Case Example
ing distance, whereas patients habitually use
A 4-year-old girl arrived with her parents for her
many near and intermedate distances in real-life
first complete eye and visin examination. The
situations. The deviation, therefore, can easily
parents reported that they saw her left eye cross
decompensate f sensory and motor fusin are
several times each day when she looked carefully
weak. von Noorden et al.13 reportad that the best
at nearpoint toys and other objects. They had
long-term results were achieved by those patients
noticed this for nearly 6 months, but it was
who underwent fusional vergence training n
becoming more frequent. There was no family his-
addition to bifocal management. We believe that
tory of strabismus or other major eye problems,
the most effective management of accommoda-
and there was no birth complication. Questions
tive esotropa ncludes a relatively short program
regarding general health, trauma, medications,
of visin training to maximize sensory and motor
allergies, and development all were answered in
fusin, followed by the prescription of retainer
the negative.
exercises and regular progress visits, once or
The relevant clinical findings were as follows: A
twice yearly, to ensure successful long-term
cycloplegic refraction (1% cyclopentolate [Cyclo-
results.
gyl] gtt) revealed a modrate amount of hyperopic
The emphasis of visin training s to break the
astigmatism:
deep suppression often found at near even with a
bifocal add and to extend the motor fusin ranges Oculus dexter (OD): +3.25 -1.25 x 090 10/10
to compnsate for an eso deviation at all viewing Oculus sinister (OS): +4.25 -1.75 x 090 10/20
distances. Specific training techniques, used in
combination with a bifocal lens, that we have With the prescription lenses in place, visual
found particularly effective with CE patients acuity testing using Lighthouse cards indicated
include Brock string and beads (T13.6), Vecto- slightly reduced far visin of the left eye, equiva-
grams and Tranaglyphs (T13.8), binocular accom- lent to 20/40 (6/12). Near acuity testing using the
modative rock with minus lenses (T13.11), and AO picture card ndicated approximately the same
vergence rock techniques (T13.12). Push-up train- difference between the eyes. Wearing the speci-
ing should be stressed with all these techniques to fied spectacles prescription, the patient had 2 A
extend the range of sensory and motor fusin to esophoria at far and a comitant, constant, unilat-
very near distances, within 10 cm. eral, left esotropa of 25A at 25 cm (her working
Successful management of CE patients with a distance) when she focused for a nearpoint tar-
very high AC/A ratio can be difficult with adds, get. No oculomotor restrictions or overactions
even when visin training is ncluded, because were found. The patent showed central suppres-
such CE patients tend to redevelop suppression at sion of the left eye at far and uncrossed diplopia
near and regress quickly. 10 In those cases n at near by Worth dot testing, which suggested
which the AC/A ratio exceeds 12A/1 D, the poten- NRC. The ocular health examination proved neg-
tial for needed strabismus surgery (a bilateral ative. The diagnosis was uncorrected hyperopic
medial recession) as part of a visin therapy pro- astigmatism, CE esotropa, and shallow amblyo-
gram significantly increases (see Chapter 7). pia of the left eye.
Chapter13 393
The parents agreed to follow the recommended tme and to put up with the mnor inconvenience
visin therapy plan: of distant blur during the spectacle adaptaton
period. Latent hyperopa may take several weeks to
1. Full correction of the refractive error with
relax in some cases. Even f the strabismus is not
spectacles for constant wear
completely corrected, the deviaton may be signifi-
2. A +2.00-D add for near, provided n bifocal
cantly reduced, thus improving the prospects for
form to help control the nearpoint devia-
success wth other therapeutic approaches.14
tion due to the patient's high AC/A ratio
Because most cases of BE strabismus are con-
3. Direct occlusion of the right eye (by use of
stant from an early age, the doctor must frequently
an Elastoplast occluder worn under the
treat amblyopa and ARC to effect a functional
spectacles) for 3 hours daily for 1 month to
cure of strabsmus. (Chapters 10 and 11 are dedi-
stimulate the development of acuity n the
cated to these discussions.) Once these sensory
amblyopic eye
adaptations are basically resolved, the clinician
4. Anaglyphic fusin games (T13.5) during
establishes normal sensory fusin at some position
the child's play time with her mother
in space, usually at near, with optics. Spectacle
At a 1-month progress evaluation, the patient's prisms, Fresnel prisms, centration-point add, plus-
condition had mproved considerably. The little addition bifocals (based on the AC/A ratio), or
girl had complied well with the wearing of the some combination of these are the optical tools
spectacles and the patch but had only occasion- available for this purpose. If sensory fusin cannot
ally played the anaglyphic games, although she be achieved at some distance by these means, then
liked them. The parents had not noticed a crossed the patient wears a patch on one eye for all dis-
eye except on rare occasions when the child tances. When optical alignment can be achieved
looked over the bifocal segments at near and at near in BE cases with a combination of prisms
when she took the spectacles off. No change in and add, but not at far, the top portion of one lens
the refractive error was found. The corrected s occluded with tape or plstic. While n a visin
visual acuities were almost equal: OD, 10/10; therapy program, the patient s not allowed to
OS, 10/12. With the bifocal spectacles, the devia- "practice strabismus." The next step toward a func-
tion measured 1A esophoria at far and 5A esopho- tional cure requires vigorous, usually in-office,
ria in down-gaze through the add. The patient visin training.
demonstrated normal reflex fusin responses to There are innumerable ways that visin training
4A Bl at near. Only occasional central suppression can be programmed. We present here an example
of the left eye was found at far. The parents were of one training program for basic esotropa that we
pleased with the visin therapy results. They were think s effectve in many cases. Only a brief ds-
instructed to continu to patch the right eye 3 cussion of each technique can be given; the reader
hours daily on weekends only, to reinforce the should refer to other sections for details.
improved acuity. The child and mother were When possible, we start visin training at near
instructed in the use of an anaglyphic reading bar distances in the open environment, as recom-
(T12.10) for antisuppression training with picture mended by Brock, 15 expanding sensory and
books. Another progress evaluation was sched- motor fusin as much as possible. We then work
uled in 3 months. to extend the learned skills to the farpoint. Wear-
ing an add or prism lenses (or both) for training at
the centration point, the patient attempts to break
Basic Esotropa suppression using a strong stimulus if necessary
Management Principies (e.g., Brock string and beads [T13.6], except that
Most cases of basic esotropa (normal AC/A ratio) two penlights are used rather than two beads).
have an assocated accommodative component The patient attempts to make small vergence
that requires full optical correction. Sometimes jumps between lights, recognizing physiologic
esotropa is caused solely by uncorrected hypero- diplopia at all times. With progress, the therapist
pa. Once the patient adapts to wearing the cyclo- replaces the lights with beads, but initially they
plegic spectacle or contact lens correction, a are directly illuminated with penlights while the
strabismus may not be found. Esotropc patients room lights are dim. The Mother Goose Vecto-
should be encouraged to wear ther spectacles full- gram, with its large suppression controls, is intro-
394 Chapter13
duced at the centration point, and vergence motivation and compliance of the patient in visin
ranges are expanded in both horizontal directions training, and the size of the resultant deviation are
(T13.8). With good suppression controls and ste- prime indicators.
reopsis clues in the visual field, vergence rock There are other cases, however, in which this
techniques (T13.12) are ntroduced to build ssue is not easily resolved. The patient or parents
reflexive step vergences. may be extraordinarily determined to avoid an
As binocular skills increase, the amount of plus- operation. Progress may be slow but steady. The
addition lenses and prism compensation is reduced, patient may have fusin most of the time after
and the training distance is ncreased. The walk- training, but comfort and visin efficiency may not
away technique (T13.9) can be used to extend the be acceptable, as in the case of esophoria of 20A or
training environment to farther distances from the greater. Should training be continued or the sur-
patient. Projected Vectograms and Tranaglyphs geon consulted? We have an arbitrary guideline to
(T13.10) and peripheral fusin rings (T13.7) help to deal with this difficult question. If the strabismic
consoldate sensory and motor fusin at the far- patient has not achieved a satisfactory binocular
point. The Bernell Mirror Stereoscope (T13.2) and visin result within a 6-month period of visin
the Brewster Stereoscope (T13.3 and TI3.4) are training with full compliance, we suggest a surgi-
excellent initially for home training. Other tech- cal evaluation and support the surgeon's recom-
niques should also be introduced for the sake of mendation in most cases. (See Chapter 6 for a
variety, patient nterest, and generalization of discussion of surgical considerations.) Postopera-
learned skills. If the patient does not progress as tive care would proceed as previously described in
expected using these techniques, amblyoscopic the section Follow-Up Care. Six-month progress
divergence training (T13.1) can be intensively evaluations are advisable in cases of BE managed
applied in an attemptto establish basic fusin. with visin therapy, especially if amblyopia has
Suppression s broken within the mximum ver- been part of the condition. We usually recommend
gence ranges that can be trained at all viewing dis- bar reading with prism rock (T13.12) once weekly
tances. Vergence facility and stamina, besides the as a retainer exercise, to prevent regression; the
perception of stereopsis, are all ncreased. These retainer training schedule, however, depends on
are the initial therapeutic goals, even f the esotro- the findings at each progress evaluation.
pa cannot be totally resolved with training.
Alignment of the strabismus comes with the train- Case Example
ing of fusional divergence in some cases, prism and This case describes a 9-year-old boy with basic
add compensation in many, and strabismus surgery esotropa of approximately 1 1 A at near and far.
in others. After full correction of the refractive error, The patient had been given the following lens
the magnitude of the resultant deviation usually prescription:
determines whether an operation is required. When
OD:+3.25-0.25 x 95 with 3 A BO 20/25+ 2
that angle measures 20A or greater, even in cases
OS:+3.75-0.25x90 with 3 A BO 20/25- 1 Oculus
having NRC, an operation often is necessary f the
uniter (OU): +2.25 add (25-mm straight top
goal is clear, single, comfortable binocular visin.
bifocal)
We have seen a few patients who have had 20A of
esophoria with no symptoms and good stereopsis, Through the top (farpoint) portion of the lenses,
but they are indeed rare. Occasionally with visin the diagnosis of the deviation was as follows: com-
training, there s a spontaneous reduction in the itant, constant, alternating (right eye preferred)
angle of deviation. Trained fusional vergence can esotropa with central suppression, NRC, only
become like a conditioned reflex and will not dissi- some peripheral sensory fusin with central sup-
pate quickly with occlusion, as on a conventional pression, and poor motor fusin ranges.
cover test. Reductions in the angle of deviation after A series of 12 visin therapy vists was pre-
vergence training, as revealed by the cover test, can scribed along with home visin training. Tech-
be transitory and may not represent the dissociated niques included cheiroscopic tracing, lose Bl
tonic vergence position of the eyes. In many cases, prism training, vectographic training to improve
the doctor will easily determine which patients stereopsis, various antisuppression techniques,
require surgery and which do not after 1-2 months Mirror Stereoscope Bl training, centration-point
of visin training. The rate of skills improvement, the training, major amblyoscope for suppression and
motor fusin training, monocular and binocular The spectacle frame needed to be replaced, and a
accommodative rock, and Root Rings for periph- prescription for 6A BO was continued; the pre-
eral stereopsis with fusin walk-aways. Progress scription remained the same n all other respects.
evaluation showed improvement in stereopsis from Although there had been no significant cosmetic
550 to 300 seconds of are; motor fusin range probiem n this case, there was a functional cure of
improved from 3A to 7A (ability to fuse from 6A BO to the esotropa according to the criteria of Flom (see
1A Bl). Central suppression was less deep and only Chapter 6). The patient was happy and expressed
foveal (whereas previously it had been macular n the feeling that his successful results of visin ther-
extent). apy were worth the time and effort.
Additional visin therapy was recommended.
Another series of 12 office visits and home training
ncluded Pola-Mirror and vis--vis (no mirror but Divergence Insufficiency
patient and therapist wearing crossed polarizing Esotropa
filters and looking at one another), pencil push- DI is a relatively infrequent vergence anomaly n
ups, fusin walk-aways, three-dot card, Keystone which the eso deviation at far s greater than the
Eccentric Cirels, Brock string and beads, major eso deviation at near, a low-AC/A case. (The char-
amblyoscope, and Dual Polachrome Illuminated acteristics of DI esophoria are discussed n Chapter
Trainer with Vectograms. In the major amblyo- 3.) The same principies apply to DI esotropa,
scope, the Bl breakpoint was 12A, with a recovery except that more ntensve and extensive visin
point of 10A Bl; BO breakpoint was 12A, with a 9A therapy is required for the strabismic condition,
recovery point. In the open environment with vec- particularly if the magnitude of deviation at far is
tographic slides, the Bl breakpoint was 11A, with a large. Differential diagnosis s important in cases of
9A recovery point; BO breakpoint was 31A, with a DI (as discussed in Chapter 7); a divergence paral-
24A recovery point. Another series of 12 visits was ysis originating from a midbrain lesin can some-
prescribed, during which many of the visin train- times imtate DI esotropa.
ing techniques just mentioned were repeated. Many patients wth DI have NRC; therefore, BO
Based on cycloplegic and manifest refractive find- prisms can be benefical. A major probiem with
ings, a new prescription for spectacle lenses, prsm compensaron for the farpoint eso devation,
including Fresnel prisms was given: however, is that the nearpoint devation may con-
sequently be increased in an exo drection n many
OD: +3.75 - 1.00 x 90 with 3A BO
of these patients. Some patients, therefore, wear
OS: +3.75 - 1.00 x 80 with 3A BO
the prism spectacles only for dedicated far vewing
OU: +2.00 add (executive bifocal)
and switch to another pair of glasses without prism
Visual acuity was 20/20 (6/6) n each eye. for reading. Others may find t dsturbing and df-
Stereoacuity had improved to 60 seconds of are fcult to adapt to constantly changing spectacles.
(contoured targets). There was no strabismus on the A temporary soluton might be to attach an
cover test with the prescribed spectacles, but a appropriate-power Fresnel BO prism to only the
residual esophoria of 2A was found when testing top half of the lenses.
through these lenses (thus a total of 8A eso devia- BO prsm for the whole lens may be prescribed,
tion). At near, the patient was orthophoric through wth caution, for some patients not needing more
the bifocal additions. The patient was able to main- than 10A of BO compensaron at far. Convergence
tain fusin for several minutes without the aid of training sometmes is necessary for the induced
the BO prisms but could not do so when the hyper- nearpont exo deviation but, more mportant,
opic lens correction was removed. The patient was fusional dvergence trainng to help control any
advised to continu wearing the bifocal spectacles remaining eso deviation at the farpoint s most def-
with prism. Subsequent progress checks indicated ntely required n such cases.
that the patient passed al I 15 cards of the Keystone Increasing the fusional divergence range at far
Visual Skills Test and had suppression-free ranges wth visin training s not easy. Progress s often
from 8A Bl to 42A BO on the major amblyoscope. slow; asthenopic symptoms frequently intensify.
On phorometry testing, the NRC was 1 7A, positive If the eso devaton at far exceeds 20 A, strabis-
relative convergence (PRC) was 31A, and negative mus surgery (most likely a bilateral resection)
and positive relative accommodation were normal. often s necessary for a satisfactory outcome.
396 Chapter13
Our approach to visin training in DI cases is peripheral sensory and motor fusin and resolu-
similar to that for BE patients (a case example, tion of their visual symptoms.
therefore, is not included here). Sensory and There are some cases, however, in which the
motor fusin is enhanced initially at near, where microesotropia is not associated with ARC. In
the patient has best control of tne deviation. As these cases, patients often experience intermit-
the patient's fusin skills increase, the training tent diplopia and asthenopia. This type of
distance also is increased toward the farpoint microtropia represents an intermedate condi-
(e.g., Tranaglyph walk-aways [T13.9]). Finally, tion between esophoria with fixation disparity
large stereo targets (e.g., peripheral fusin rings and a manifest esotropa. Such patients with
[T13.7] and projected Vectograms [T13.10]) are microesotropia often respond well to prism com-
introduced at the farpoint to help the patient pensation, plus adds, and antisuppression and
make the required divergence movements with- divergence training, as the following case exam-
out suppression. In-office and home training ple demonstrates.
may take 3-4 months.
We have found that rigorous retainer exercises Case Example
usually are needed to maintain the results of diver- A 16-year-old boy presented with blurred visin at
gence training. We suggest using either a lose far while wearing his myopic spectacles and
prism or flippers for vergence rock (T13.12), com- requested contact lenses. He was more comfort-
bined with a televisin trainer. The goals are to able reading without his glasses and occasionally
build divergence facility while monitoring suppres- noticed double visin when he was tired. Only
sion for 30 minutes at least once weekly. pertinent data regarding binocular status are
included in this case example.
Habitual lenses and acuities were as follows
Mkroesotropia (note that J1 [Jaeger test type 1] is considered nor-
Management Principies mal visual acuity at near):
Microtropic patients generally have a stable bin-
OD: -3.00 DS 20/40 (6/12) J1 at 40 cm
ocular condition and do not report visual symp-
OS: -3.00 DS 20/40 (6/12) J1 at 40 cm
toms. ARC and reduced stereopsis are expected;
many also have amblyopia. If the amblyopia in With the patient wearing his habitual lens correc-
these cases is worse than 20/30, we often recom- tion, the unilateral cover test showed a constant,
mend a short-term patching program to improve unilateral, right esotropa of 3A at 6 m and a con-
it. The goal is to ensure that the patient has good stant, unilateral, right esotropa of 22A at 40 cm.
visual acuity in each eye even though there is no There was a latent deviation of 20A at 6 m on the
central fusin. Other than treating amblyopia altrnate cover test. When the cover was removed,
(see Chapter 10), we rarely try to cure the there was a fusional recovery movement to within
microtropia unless the patient has asthenopic 3A of ortho at far, but no recovery was evdent at
symptoms. We have found that in cases of symp- near. Hirschberg testng in all fields of gaze nd-
tomatic microtropia, symptoms often abate with cated comitancy wth good pursuit and saccadc
standard sensory and motor fusin training. eye movements. The Worth dot test showed modr-
Prisms usually do not help because of prism ate suppression OD at far and homonymous dplo-
adaptation, but a plus-addition lens may help if pa of five dots at near. Hering-Bielschowsky
an accommodative deficiency exists. Suppression afterimage testing ndicated NRC, and Bagolini str-
may be partially broken with a televisin trainer ated lens testing showed that angles S and H were
(T12.8) and Brock string and beads (T13.6). Ver- equal. The microtropia was neutralized with 3A BO;
gence ranges are increased with sliding Vecto- there was no movement on the unilateral cover test,
grams (T13.8), the Mirror Stereoscope (T13.2), but a large esophoric movement was observed. Sub-
and the major amblyoscope (T13.1), if necessary. jective refraction (dry) was as follows:
However, in most cases, although symptoms are
OD:-4.00-0.25x120 20/15(6/4.5)
resolved, the microtropia as measured by unilat-
OS:-4.00-0.25x180 20/15(6/4.5)
eral cover test persists. Patients usually consider
this to be a satisfactory result, and we accept With these CAMP lenses, a +3.00-D add with
their judgment. These patients have enhanced 3A BO neutralized the esotropa at near. Wearing
Chapter13 397
this optical combination, the patient had 60 sec- fusin skills but to return for evaluation f fusiona!
onds of are on the Stereo Fly test. Motor fusin control started to diminish. The patient's binocu-
ranges, however, were not measured because of lar status appeared to be stable, and he was
suppression. advised to return for another progress check in 6
These binocular findings are unusual because months.
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 Esophoria
patient demonstrated peripheral fusin at far but Management Principies
not at near. (Refer to the discussion of microtro- Our preference n treating symptomatic esopho-
pia n Chapter 7.) It is likely that the potential for riaall three typesis to correct fully any signifi-
sensory fusin was always good because the cant refractive error, then prescribe fusional
patient would habitually read without his specta- divergence training to determine whether symp-
cles, as though having an add for fusing at his tomatic and performance problems can be abated.
centration point. If not, we prescribe prisms, plus-addition lenses, or
The visin training plan included prescribing some combination of these. As regards the pre-
CAMP spectacle lenses to solve his probiem of scription of prism, we usually apply at least one of
blurred visin at far, which was the patient's only three clinical criteria:
complaint. The plan also included prescribing BO
1. Clnica! wisdom recommends completely
prism and an add at near n the form of bifocals, to
compensating for the eso deviaton f the
promote fusin at far and near. The patient was
devation measures 10A or smaller. Larger
reluctant, however, and wanted contact lenses for
amounts are given partially compensating
cosmetic reasons. The patient made a compromise
prisms.
and agreed to accept the following: soft contact
2. Sheard's criterion should be met.
lenses for social occasions and, for study and criti-
3. Associated phoria (as measured by the
cal viewing occasions, plano spectacles having 4A
Mallett, Bernell, Saladin, or other vecto-
BO overall (for fusin at far) and a bifocal add of
graphic or anaglyphic tests) with a central
+3.00 (for fusin at near) to be worn with the con-
fusin target should be neutralized.
tact lenses.
Vision training with weekly office visits and Sensory and motor fusin training proceeds
daily home training was conducted for 3 months. much n the same pattern as s recommended for
The techniques and sequence generally followed the corresponding types of esotropa. (Refer to the
the program for basic esotropa discussed previ- earlier section, Vision Therapy Sequence for Eso-
ously. Emphasis, however, was on the use of phoria, and Table 13-4.) Initally, we suggest an
physiologic diplopia with Brock string and beads, emphasis on training ocular motility, ncluding
a televisin trainer and prism rock, and the Spi- accommodation, f a dysfunction exists. When
rangle Vectogram. At the conclusin of visin vergence skills are introduced, t is prudent to
therapy, there was no movement on the unilateral include convergence ranges as well as divergence
cover test at far or near, although there was a ranges. This is because convergence ranges
latent eso deviation of 20A at far and 2A at near expand quickly, which is an encouraging result
(testing done with contact lens-spectacle combi- for the patient. Divergence ranges expand slowly,
nation). Motor fusin ranges with the Spirangle but divergence facility may ncrease rapidly with
Vectogram were 15 A Bl and 20 A BO, and the training. We, therefore, stress phasic (i.e., step
patient was free of suppression. Stereopsis was 40 and jump) over tonic (i.e., sliding and trombon-
seconds of are (Stereo Fly test). ing) exercises when training divergence. Isometric
The patient had not shown any regression in exercises also seem to be an efficient approach in
binocular skills after 2 months. His vergence the treatment of esophoria. The patient can be
ranges had not diminished but had actually instructed to read while wearing a Bl prism or a
increased. The patient had no symptoms and was minus-lens add for a predefined period. This train-
happy with the contact lens-bifocal combination. ing of divergence by optical means may cause
He was nstructed to continu home visin train- some eyestrain, and so frequent breaks may be
ing for 10 minutes once monthly to monitor needed.
398 Chapter13
In our experience, visin training can often be gery for esophoric patients, however, is the
effective in cases of esophoria, using a home- exception rather than the rule.
based program augmented with in-office ther-
apy. Complete training usually takes 8 -12
weeks. Without retainer exercises, divergence REFERENCES
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Good retainer exercises are the Aperture-Rule 2. Major D, Pirotte P, Griffin JR. Orthoptic Therapy with
Microcomputer: A Comparative Study. Research project.
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On file n the M.B. Ketchum Memorial Library, Southern
Either or both of these can be assigned for a 20- California College of Optometry, Fullerton, Calif., 1985.
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a decrease in divergence skills or a recurrence of sustained mprovement after short isometric exercise. Am
suppression, he or she should return for a } Optom Physiol Opt. 1979;56:23-33.
4. Ciuffreda KJ, Levi DM, Selenow A. Amblyopia: Basic and
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Clinical Aspects. Boston: Butterworth-Heinemann; 1991:
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Deviations: The Effect of Wearing Compensatory Prisms
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in cases of esophoria. We have, however, seen Library, Southern California College of Optometry, Fuller
patients with large esophoric deviations who ton, Calif., 1972.
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Optom Weekly. 1972;63:629-632.
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for evaluation and therapy of binocular anomalies. J Am
even with the compensating prisms in her spec-
Optom Assoc. 1983;54:785-788.
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but, because of lack of time and finances while thalmol Strabismus. 1985;22:238-242.
in college, she deferred the surgery until after 11. von Noorden GK, Avlla CW. Nonaccommodative con
vergence excess. Am J Ophthalmol. 1986;101:70-73.
her graduation. The deviation was reduced to
12. Caloroso EE, Rouse MW. Clinical Management of Strabis
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of the medial rectus of the nondominant eye. 13. von Noorden GK, Morris J, Edelman P. Efficacy of bifocals
The patient was able to discontinu wearing the in the treatment of accommodative esotropa. Am J Oph-
BO relieving prisms. Although her symptoms tha/mo/. 1978)85:830-834.
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Anomalies. In: Principies and Practice of Pediatric
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Chapter 14 / Vision Therapy for Exo Deviations
Exo deviations are more prevalent than eso devia- time2 and are, therefore, considered intermittent.
tions. The ratio regarding strabismus is approxi- Many of these individuis experience visual symp-
mately 3 to 2, which transales nto approximately 5 toms of eyestrain, fatigue, diplopia, blur, and photo-
million people having some form of exotropia (XT) phobia. Exophoria (XP) has been found to be
in the United States.1 Approximately 80% of exo- associated with visual symptoms while reading and
tropes have fusin at some distance at least part- also with poor reading skills. 3'4 Because so many
400 Chapter14
DIAGNOSTIC CONSIDERATIONS
TABLE14-1. Vision Therapy Sequence for
Comitant Exotropia Cases of exo deviations, either XT or XP, may be
categorized into three types: divergence excess
(DE), with a high accommodative-convergence/
1. Correction of any significant ametropia, even accommodation (AC/A) ratio; basic exo (BX) with
modrate to high hyperopia a normal AC/A ratio; and Cl, with a low AC/A
2. Treatment of amblyopia, if present, improving ratio. (See Chapter 3 for definitions and discus-
visual acuity to at least 20/60 (6/18) sion of these types.) Both DE and BX are consid-
3. Training basic ocular motHity of each eye: fixatlon, ered to be primarily farpoint problems, as poor
saccades, pursuits, and espectally accommodation cosmesis, deficient sensory and motor fusin, and
4. Gross convergence training if there is no fusin at symptoms are relatively more likely with far
near, even in cases of anomalous retina! corre- rather than with near viewing. Although in BX
spondence cases the exo deviation is approximately the
5. Classic anomalous retina! correspondence therapy
same at all distances, the fusional "glue" s
if gross convergence training is unsuccessfut and
weaker at far than at near (e.g., less stereopsis,
prognosis for its elimination is favorable
smaller retinal images, and lack of tactile-kines-
6. Sensory alignment of the eyes at some or all dts-
thetic feedback). In contrast, Cl XP and XT almost
tances using any combination of prisms and added
lenses (assurning NRC)
exclusively cause nearpoint problems. As com-
7. Antisuppression therapy, if NRC present, to estab- pared with DE and BX, successful treatment of
lsh diplopia awareness and basic sensory fusin cases of Cl is usually easy.
8. Central sensory and motor fusin training, f NRC It is worthwhile remembering that XT may
present, to achieve good stereopsis and mximum present some diagnostic challenges and that accu-
fusional vergence ranges, free of suppression, at racy in diagnosis affects the type and sequence of
atl viewing distances visin therapy. (See discussion n Chapter 6.) These
9. Strabismus surgery, if necessary, to reduce the challenges include the following considerations:
angle of deviation to within the range of reflex First, sometimes the true far and near angles of XT
fusional vergence are larger n the open environment than is found in
10. Prescription of compensatory prisms and added the examination room, for as-yet inexplicable rea-
lenses as needed sons.9 Second, there exists a high prevalence of
11. Development of good monocular and binocular "simulated" DE exotropic cases, usually BX cases,
efficiencyskills for which a prolonged cover test s needed to
12. Maintenance home exercises and periodic reveal the full magnitude of the near deviation.10 A
progress checkups differential diagnosis must be made between a
NRC * normal retina! correspondence. case of true DE and BX. Third, n cases of ntermit-
tent XT, the clinician needs to be aware that
fusional control of the deviation can vary consider-
patients with exo deviations have some fusional ably, depending on the patient's general state of
ability, and because fusional convergence is rela- health and degree of fatigue. With these consider-
tively easily increased with training,5'6 visin training ations in rnind, the clinician may avoid making
is often the preferred therapeutic option applied in these diagnostic errors that can result in case
these cases. Using visin training and surgery, mismanagement.
Flom7 reported that the functional curejate for most
cases of constant XT is approximately 40-50% and,
for intermittent XT, 70-80%. In an extensive review
article on visin training results n exophoric con- VISION THERAPY SEQUENCE
vergence insufficiency (Cl), Grisham8 found a 72% FOR COMITANT EXOTROPIA
cure rate that included among the criteria relief
from ocular symptoms. Our clinical experience is Our recommended sequence of steps for visin
consistent with these observations: Successful treat- therapy n the management of comitant XT is out-
ment of exo deviations is generally easier than that lined in Table 14-1. The clinician should adminis-
of eso deviations, and visin training is usually part ter only the steps that are appropriate for a
of our treatment plan, often the most important part. particular case on the basis of the diagnosis.
Chapter14 401
Correction of Refractive Error Because most exotropes fuse at some distance, usu-
Exotropes tend to have a higher prevalence of myo- ally at near, they covary from ARC to normal retinal
pia and myopic anisometropia than do people in the correspondence (NRC) when fusional vergence
11 12
general population. - Even small degrees of myo- movements align the eyes. When the exo deviation
pia, astigmatism, and anisometropia (e.g., 0.75 s manifest, however, they covary back to ARC. Even
diopters [D]) can be an obstacle to control of the in cases of constant XT, ARC often is not an overrid-
deviation n some patients. Certainly, n cases of XT ing consideraron f the patient can learn gross con-
in which fusin s the goal, we believe that the clini- vergence (T11.13). On the other hand, ARC does
cian should correct small amounts of refractive error. become a serious obstacle to progress in constant
Exotropic and exophoric patients can have any type XT when gross convergence techniques fail to align
of refractive error, even large amounts of hyperopia. the eyes at near, with covariation to NRC. If classic
Modrate to high degrees of hyperopia should be amblyoscopic techniques for eliminating ARC are
corrected; one report indicated that cure was necessary n cases of constant XT, the same prob-
achieved n some hyperopic exotropic children lems and restrictions limit success as in cases of
18
(ranging from 3 to 7 D) with spectacle correction, constant esotropa (see Chapter 11). Wick demon-
whereas all others n this series of seven experienced strated that success is possible, even n the case of
13
mproved binocular sensory status. Many modrate an adult with constant XT. We believe success s
to high hyperopes do respond to plus lenses with an possible n many such cases. However, there are
increase in the exo deviation, as expected, based on considerations that can make treatment impractical
the AC/A ratio. Even so, t s advisable to relieve the for the patient: Vision training may be time-consum-
stress on accommodation; sometimes the ing, difficult, and expensive.
fusional status is remarkably mproved, as the previ- Deep suppression, if present, can also be a sig-
ous report indicated. nificant obstacle to establishing sensory and motor
Most authorities agree that large XP and intermit- fusin. As with ARC, t s best to stimulate gross
tent XT n childhood tend to decompensate over convergence (T11.13); it is hoped that the patient
time and become constant f left untreated. "
14 16 can attain peripheral fusin at some near distance.
17
Hiles et al., however, reported a clinical series of Antisuppression training can begin at this position
48 intermittent exotropes whose sol treatment was in the open environment.
correction of their refractive error. These patients
were followed up for several years; 65% became
Gross Convergence Training
phoric and, n 73%, the magnitude of their exo
deviation was reduced. We believe that correction As indicated in the previous discussion, we believe
of the refractive error remains the primary step n t s very important in cases of XT to attempt gross
treating most binocular anomalies. convergence training (T11.13) early in the therapy
sequence. This technique is usually unnecessary,
however, in cases of DE, because these patients
Elimination of Major frequently have fusin at near (.e., intermittent
Sensory Anomalies exotropia at near [X(T')]). The need arises more
Amblyopia is not usually associated with XT, often in cases of BX of large magnitude and n
because most of these deviations are not constant. cases of Cl XT. Any exotrope not having nearpoint
In those XT cases in which amblyopia exists, how- sensory and motor fusin should attempt this tech-
ever, t s important to improve visual acuity to nique, even on the initial diagnostic visit. If suc-
approximately 20/60 (6/18) before proceeding cessful, the prognosis for a functional cure
with binocular therapy. It is also necessary for the increases. Training time usually decreases, and the
patient to have good ocular motility at this point in patient can avoid much closed-instrument training.
the sequence (i.e., good fixation, pursuits, sac- Even when the technique results in fusin at near
cades, and accommodation). If these skills are for only 1 minute, the patient can be considered,
deficient, they should be the immediate concern n for practical purposes, an ntermittent exotrope,
visin training (see Chapters 10 and 16). and the. prognosis dramatically increases by 30%
7
Anomaious retinal correspondence (ARC) usually according to Flom's chart (seeTable 6-4). We con-
is not a significantly unfavorable factor n cases of sider gross convergence sufficiently important that
XT and s no problem at all in XP (see Chapter 11). we will spend two or three n-office training ses-
402 Chapter14
sions trying to develop t before resorting to encourage the clinician to evalate the effect of
amblyoscope training (T14.2). Even then, t should minus adds in all cases. As part of their evaluation,
be periodically attempted as visin training contin- some doctors have a stock of -3.00-D loaner spec-
es in closed-space nstruments. (See the discus- tacles that they give to patients for a 1 -week trial
sions of techniques T11.13 and T14.1.) period. We have found this aggressive approach to
be effective n many cases.
In addition, t is often appropriate to assign some
Compensating Prisms and accommodative techniques for home training so
Lens Additions that the patient can derive mximum benefit from
Base-in (Bl) prism compensation should be tried n the minus-add loaners. Some older children and
cases of XT f NRC exists. The goal is to obtain sen- adults may experience accommodative asthenopia
sory orthophoria by optical means so that fusional due to the over-minus lenses; visin training may
reflexes are encouraged. Typically n cases of XP help to relieve this discomfort. Another possible
and XT, it is not necessary to prescribe the total adverse consequence to minus-lens overcorrection
amount of compensatory prism, as measured by is that of causing or increasing myopia. However, a
cover test, to elicit a fusional convergence response; study by Rutstein et al.22 found that the rate of myo-
one-third to one-half the angle may be sufficient. pia progression with minus-lens overcorrection was
Many exotropes do not show prism adaptation in no greater than expected during the usual course of
response to Bl prism, and their fusin remains stable myopia development. Nevertheless, the clinician
for many years.19 Patients n whom ARC and sup- should remain alert for unexpected changes in the
pression are present when the eyes are in an exotro- patient's refractive status during this treatment.
pic position may require Bl prism compensation to The amount of minus addition that s most effec-
achieve nitial success. A trial period of wear (a few tive for a particular patient mus be determined by
days) using Fresnel prisms may help to determine direct observation of the effect of various lens pow-
the efficacy of relieving prisms. ers on the angle of deviation and the patient's
If the exo deviation has an associated vertical fusional control. The calculated AC/A ratio can give
component, as s frequently the case,20 the effect of the clinician an dea of which amount to try first.
vertical prism on the patient's control of the hori- Typically, this amount yields less effect than would
zontal deviation should also be evaluated carefully. be expected by calculation, because patients usu-
Vertical prism is usually necessary only when the ally do not accommodate fully in response to the
vertical deviation s primary and not simply second- lenses. It is usually unnecessary, however, to com-
ary to the exotropic posture of the eyes. If the pnsate the angle of deviation completely. One
patient can fuse, vertical fixation disparity measure- practical criterion s to prescribe the lowest amount
ment indcales the necessary prism prescription. of over-minus power that gives the fastest reflex
An efficient means of eliciting fusional vergence fusin response. A trial-and-error method can be
is by aligning the eyes with minus-lens overcorrec- used to determine this amount. Trial lenses are
tion. Caltrider and jampolsky21 reported that 72% placed before the patient's eyes. Using a cover pad-
of their young (2- to 13-year-old) intermittent exo- dle to break fusin, the clinician observes the
tropic subjects (N = 35) became well-controlled speed of the fusional vergence movement when the
XPs using minus-lens overcorrection as the sol occluded eye is uncovered. Alignment should
intervention. The effect of minus adds should be occur by reflex; the patient is instructed to avoid
evaluated n all nonpresbyopic exotropic patients, voluntary convergence. The shorter that the ver-
even Cl cases, but particularly n those having a gence response latency is and the faster the veloc-
normal or high AC/A ratio (i.e., BX and DE cases). ity, the better. Additional increases in power do not
Sometimes even a small amount of accommoda- always result n a more vigorous fusin reflex;
tive stimulus is sufficient to initiate a fusional con- therefore, the lowest power that produces the mx-
vergence response. In other cases, 2 or 3 D of imum response s selected.
over-minus power may be required to reduce the An interesting and seemingly paradoxical use of
angle of deviation substantially to within the range added lenses to build fusional control of intermit-
of reflex fusional vergence. When the patient has a tent XT nvolves the prescription of a plus-lens
large-angle basic XT (40A or more), minus adds bifocal. If the patient shows an XT at far and an XP
usually have no significant effect. Nevertheless, we at near (which s often the case), an sometric
Chapter14 403
fusional vergence technique may be effective. The with covariation; suppression can be more easily
idea s to increase the magnitude of the habitual broken in the ortho posture with NRC than when
XP at near with a plus add. This increased XP the eyes are n the exo position with ARC.
requires the constant exertion of greater fusional As in training n cases of eso deviations (see
convergence at near. Over time, this helps the Chapter 13), the doctor should be sure that the
patient to control the farpoint deviation. The monocular visual skills of saccades, pursuits, fixa-
patient should be warned of nearpoint asthenopic tion, and accommodation are adequate before ver-
symptoms and must be willing to endure them. gence training begins. The principal difference n
This optical isometric method of training fusional visin training between cases of eso and exo devia-
convergence may be appropriate for those patients tions is the emphasis on Bl training for eso and
who cannot actively particpate n a visin training base-out (BO) for exo deviations. Many of the tech-
program. Careful periodic monitoring of the effect niques for both conditions can be used interchange-
of the lenses is needed to ensure control of the ably with only minor differences in techniques.
near deviation without suppression. Only a sampling of possible training techniques s
In an extensive review of the literature, Coffey et included in this text, for the sake of brevity.
al.23 found that the functional success rate n inter-
mittent XT using Bl prism or a minus add as a sol Changing Viewing Distance
ntervention was the same, 28%. This review sur- The approach to sensory and motor fusin training
veyed more than 200 patients n each therapy cat- n cases of farpoint exo deviation nvolves increas-
egory. We rarely use these techniques as solated ing the viewing distance of a fixated target. When
treatment modalities. Rather, they are usual ly com- a DE patient bifixates a receding object, there s an
bined with sensory and motor fusin training. increasing demand on fusional convergence,
because the exo deviation is larger at far than at
near (see Chapter 3). It seems counterintuitive at
Sensory and first to do push-aways and walk-aways to cure XT,
Motor Fusin Training but the efficacy of this approach is understood
General Considerations when the relation between the AC/A ratio and the
It bears repeating that during a visin training pro- ortho demand line is taken into account.
gram for strabismus, the patient should never be Changing the viewing distance in the open envi-
allowed to reinforce the strabismus. If the strabis- ronment s an effective approach to building sen-
mus is constant, then occlusion to treat or prevent sory and motor fusin skills in cases of intermittent
suppression or other sensory adaptations must also XT and XP. Sensory and motor fusin training
be constant. For example, if after a good effort with should ideally be ntroduced and enhanced at the
gross convergence training n a Cl exotropic case, distance at which the patient can successfully fuse
fusin at near has not been achieved, except dur- in the open environment. If fusin is absent and
ing active training, the patient must still wear a gross convergence is unsuccessful, then training
spectacle half-patch (lower portion of the lens) for can start on the major amblyoscope in the office
nearpoint viewing. However, if this patient fuses and with a Bernell Mirror Stereoscope at home.
60% of the time and loses fusin n the afternoon (See Appendix J for manufacturer information
and evening, the patch need be worn only during related to trade products cited in this chapter.)
the latter part of the day. Patching alone may result Usual ly the patient can fuse, at least part-time, at
in a cure of intermittent XT. In a clinical series some distance. In this case, fusional skills are
reported by Cooper and Leyman,10 4 of 11 cases increased initially at that distance, and then train-
(36%) reverted to an exophoric condition when ing S'directed toward the viewing distance or posi-
occlusion was used as the sol treatment modality. tion of gaze in which control of the deviation is
Suppression must be addressed first. (Refer to weak or lacking. Pencil push-ups or push-away
Chapter 12 for antisuppression therapy.) Eliminat- techniques (T14.13), whichever are appropriate
ing suppression at far s not always easy. The best (based on the patient's AC/A ratio), are ntroduced
approach is to have the patient achieve alignment, at a position in the open environment where the
even if temporary, by use of minus-lens overcor- patient can best maintain sensory and motor
rection and mental effort (voluntary convergence). fusin. To extend the range of training distances,
When the eyes are aligned, the ARC is eliminated the patient can slowly walk away or walk toward
404 Chapter14
Surgical Management
TABLE14-2. Common Surgical Procedures
General Considerations
for Exotropia
Cenerally speaking, f a patient has an intermittent
A
XT greater than 25 at far or near or a constant XT
A
Divergente excess exotropia: Weaken both lateral rec-tus greater than 20 , the possibility of strabismus sur-
muscles with a bilateral recession procedure that gery needs to be discussed with the patient or par-
decreases the deviation at far primarily. Convergente ents, whichever is appropriate. The larger the
nsuffidency exotropia: Strengthen both medial rectus angle, the more likely t s that an operation will be
muscles with a bilateral resection procedure that required for successful long-term management. It
decreases the deviation at near primarily. Basic exotropia: s important to remember that intermittent exotro-
A
If angle <50 , unilateral recession and resection. If angle pic patients should undergo a prolonged cover test
d A A
>50 and <75 , a three-muscle operation. If angle >75 , to determine the full angle of deviation and
bilateral recession and resection. Immediate unmask any latent deviation. The degree of
A
postoperative goal: 10 overcorrection to ortho. 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
the stimulus target (e.g., a Vectogram or Trana-
vary according to the type of XT and are summa-
glyph) while attempting to hold fusin. The goal s
rized n Table 14-2. In cases of true DE, the pre-
to extend sensory and motor fusin to al I distances
ferred operation is bilateral lateral rectus recession.
and positions of gaze in the open environment.
This type of operation has the effect of reducing
the AC/A ratio while decreasing the magnitude of
Efficacy ofTreatment
the XT. The generally preferred operation in Cl
Vision training, as a sol intervention, has been cases is bilateral medial rectus resection, which
used extensively and with good results in the treat- has the effect of increasing the AC/A ratio. In cases
ment of intermittent XT. In one clinical series of 31 of BX, the surgeon may elect to perform a reces-
exotropes, most having constant deviations, Sanfil- sion of the lateral rectus and a resection of the
24
ppo and Clahane reported a success rate of 64% medial rectus muscle of the same eye, usually the
and a failure rate of only 3%, with little regression strabismic eye. This recession-resection (R-and-R)
after 4.5 years. Success was defined as no strabis- operation tends to have little effect on AC/A magni-
mus at far or near and good fusional vergence 28
tude. According to Helveston, when the angle of
ranges. These authors concluded that the size of A
deviation s larger than 50 , the surgeon often
the deviation and age of the patient were not operates on three muscles (e.g., an R-and-R on the
mportant factors in achieving successful results strabismic eye combined with a lateral rectus
but that patient motivation was. recession of the dominant eye). Deviations larger
25
Goldrich presented a series of 29 intermittent A
than 75 often require a four-muscle operation, a
exotropes of the DE type, this type of XT being the bilateral R-and-R. Although there are differences of
most difficult to treat solely with visin training. opinin, most surgeons try to achieve an immedi-
He reported a success rate of 82% and defined A
ate postoperative result of no more than 10 eso, a
success as the presence of a phoric condition after 29
siight overcorrection. The healing process often
treatment, no symptoms, and normal fusional results in a shift back n the exo direction. Henee,
ranges. Only one patient made no progress. The leaving a postoperative residual exo deviation
average number of in-office training sessions was increases the risk that the patient will revert to an
29, with a standard deviation of 14. 29
XT at a later time. For this reason, some surgeons
Other equally impressive clinical series have use adjustable sutures on one muscle so that post-
26 27
been reported n the literature. ' In their litera- operative refinement of the deviation s possible.
30
therapists can use. The techniques we present here Once the patient with XT learns gross conver-
generally follow a sequence from treating the most gence or voluntary convergence, he or she should
difficult cases, as n XT with poor sensory and attempt isometric exercises to hold the eyes n full
motor fusin, to treating the least difficult cases, as convergence posture for a reasonable period, at
in XP with relatively minor deficiencies of sensory least 1 minute. This exercise requires great effort
and motor fusin. The clinician should choose and a high level of convergence control and stam-
those techniques that are most appropriate for the ina; consequently, t often causes significant eye-
particular skill and nterest level of each patient. strain. The patient should be given frequent rest
breaks between training intervals.
Peripheral Fusin Rings (T14.3) instrument is ideal for home training for exotropes
Peripheral fusin targets such as the Root Rings who cannot achieve fusin at any distance either
(see Figure 13-9) can be used to build fusional by gross convergence (T11.13) or by voluntary
convergence at far. This technique is, therefore, convergence (T14.1). Even larger angles can be
particularly appropriate in cases of DE and BX. considered by using Bl prism or a minus add. Slid-
(Peripheral fusin rings were described in the pre- ing vergence training with the Bernell Mirror Ste-
vious chapter for building divergence at far in reoscope is similar to that described for T13.2 in
cases of eso deviations [T13.7].) The patient is the previous chapter in cases of esotropa. The
instructed to fixate the center stereo configuration emphasis in exo devations, however, is to increase
while wearing red-green spectacles (red on right fusional convergence ranges rather than the diver-
eye and green on left eye). If sensory and motor gence ranges, although traning should ultmately
fusin are present at some intermedate distance, include both horizontal directions. Second-degree
the patient moves to that distance from the rings targets with large suppression controls are initially
target to establish fusin initially. If the XT is con- aligned at, or cise to, the subjective angle of devi-
stant at all distances, the deviation may require ation, where sensory fusin is most likely attain-
neutralization with Bl prisms or, possibly, with able. If suppression occurs, light from a desk lamp
minus-add lenses. The patient stands at the inter- can be directed onto that field while the patient
medate distance from the target and is nstructed blinks the suppressing eye. A pointer can also be
to maintain the floating effect while slowly walk- moved around and about in the suppressed field to
ing away, as far as possible, and fusing the target. break the suppression. When the patient achieves
As fixation distance s increased, the rings should sensory fusin, BO demands are slowly increased
appear to be floating closer. (This assumes that the (or Bl decreased) as the patient attempts to main-
target is oriented upright to crate crossed dispar- tain fusin. An initial goal is for the patient to
ity for stereopsis.) The effect is fascinating and achieve a sliding vergence range from 10A BO to
motivates many patients to continu visin train- 10A Bl range around the angle of deviation. As
ing. Fusional convergence ranges are gradually training progresses, the patient attempts to reach
built up by reducing the Bl compensaron and by and then exceed the ortho position. Speed of ver-
eventually introducing BO prism of progressively gence is not an initial objective but definitely is a
greater power. later objective. An ideal goal would be to ncrease
Another anaglyphic target for peripheral fusin vergence ranges (e.g., blurpoint, breakpoint,
training is the Bernell 500-series variable Trana- recovery point) to conform to the normative near-
glyph. (Figure 13-10 shows the design of this ring point vales listed in Chapter 2, but this may be
target.) An advantage of this target is that it also impractical depending on the size of XT. The usual
can be used on a televisin screen, which makes training period for this technique is 10 minutes of
it ideal for isometric training at far. In addition, continuous activity of moving the targets between
watching of televisin often improves the training the limits of convergence and divergence.
compliance of many patients. A BO prism, either When the patient can fuse a great deal of the
Fresnel or a regular lose plstic prism, can be time, as in XP or intermittent XT, a break-and-join
attached to the spectacles to crate a challenging jump technique can be used with the Bernell Mir-
convergence demand. Later, flipper prisms are ror Stereoscope. With central second-degree
used to develop step vergence facility. Jump ver- fusin targets in position, the wings of the instru-
gence facility can be introduced by using a pencil ment are adjusted to a convergence demand on
for nearpoint fixation and instructing the patient the vergence scale that is appropriate for the
to altrnate fixation from the fused rings at far to patient's ski 11 level. The patient looks over the top
the pencil tip, continually repeating this tech- of the instrument at a distant target (e.g., televisin
nique for several minutes. trainer with peripheral fusin rings) and fuses that
target. Fixation then is quickly alternated to the tar-
gets in the Bernell Mirror Stereoscope, and fusin
Bernell Mirror is attempted. This training variation allows for sup-
Stereoscope (T14.4) pression monitoring at both distances. The patient's
The Bernell Mirror Stereoscope (see Figure 13-1) goal is to increase the speed of jump vergences
can be set for an angle of deviation of 40 A Bl. This maximally, without suppression. The rate of
Chapter14 409
Physiologic Diplopia
Brock Strng and Beads (T14.5)
The Brock string and beads technique provides a
convenient control for suppression (physiologic
diplopia) while motor fusin training proceeds (see
Figures 12-7 and 12-8). This s especially appropri-
ate for ntermittent exotropic patients, who have a
tendency to suppress. The Brock string and beads
technique has many variations, some being
described for use with suppressing patients (T12.7)
and esotropes (T13.6). With thorough instructions,
most patients can effectively use this simple device
for home training.
Because most exotropes fuse at some distance,
one bead can be set at that particular distance and
the others at more challenging positions on the
string. The patient can make jump vergence move-
ments from one bead to the others to build accu-
racy, range, speed, and stamina. The patient s
nstructed to perceive accurate bifixation (string FIGURE 14-1Nearpoint convergence training with a three-dot card.
images crossing at the fixated bead) and physio-
logic diplopia of the other beads before changing
fixation to a nearer or farther bead. physiologic diplopia of the nonfixated dots when
Gross convergence can be trained with a push- one pair is fused. Because one side of the card has
up variation of T14.5. The patient slowly moves a red dots and the other has blue, the fused dot
bead from arm's length toward his or her nose should appear as a blend of purple. The dots are
while maintainmg bifixation on that bead and per- printed n three sizes, and the card is held with the
ceiving physiologic diplopia of the other beads. largest dot farthest away.
The goal s to achieve vergence smoothness over a Because the septum s dissociative, the patient
large range (.e., tromboning). Flipper prisms com- may have trouble converging. Two options might
bined with the Brock string and beads provide step help. First, let the patient practice on the Brock
vergence training. Vergence training n various string and beads. This should be relatively easy, as
fields of gaze s also conveniently accomplished the beads can be moved farther away and there s
by asking the patient to hold his or her head n var- no septum involved. Another helpful means is to
ious positions while holding the string to the nose move the card a few centimeters away from the
and maintaining bifixation on a particular bead. patient's face to achieve fusin initially, such as on
This open environment technique, with its many the most remote dot. Once this is accomplished,
variations, s appropriate in most cases of ntermit- the card s brought closer to touch the nose, and
tent XT and XP. fusin of the middle and nearest dots s attempted.
Another way to assist the patient on the three-dot
Three-Dot Card (T14.6) card s to remove the dissociating septum by cut-
A three-dot convergence card, such as the one for- ting off the top portion of the card down to the top
mally known as the Allbee Card (Figure 14-1), s of the dots (Figure 14-2). The patient can then look
an excellent convergence stimulus at near. It can directly at the dots without dissociation. When the
also be used effectively as a home training tech- patient can quickly change fixation from one dot
nique n most cases of XP and XT. Based on the (fused pair) to another while appreciating physio-
same principie as s the Brock string, the dots rep- logic diplopia, the regular card (uncut) s substi-
resent the beads; the patient should appreciate tuted. The patient works on this technique until
410 Chapter14
reflexes that are fast and accurate. Fusional con- the patient s to reach the mximum limit of ver-
vergence can be increased with sliding, step, gence in either direction and to recover fusin on
jump, trombonmg, and sometric training using each pair as quickly and accurately as possible.
Vectograms and Tranaglyphs. There are countless The clinician prescribes as many sets as the patient
variations and embellishments of these familiar can complete within a 10-minute training session;
themes that result in many more effective training this training also benefits stamina.
techniques than can be published in any book. In relatively rare cases of XT in which the patient
Innovation n visin training is limited only by the cannot achieve any fusin at near, split Vectograms
creativity of the therapist. or Tranaglyphs can be placed at the patient's
objective angle of deviation in an attempt to obtain
Converge/ice Training at Near (T4.9) sensory fusin. Fusional convergence training pro-
The majority of patients with XT have the ability to ceeds n a fashion similar to that just described,
fuse at near at least some of the time. In such cases, except that the starting point may be with Bl com-
the target demand of a Vectogram or Tranaglyph s pensation rather than at the ortho demand point
set at the ortho position, and fusiona! convergence As progress s made, the Bl demand s reduced
training can begin with the gradual ntroduction of gradual ly and, eventual ly, a normal BO range is
BO prism demand. The Mother Goose Vectogram achieved. This technique works well if there s
(see Figure 13-11 e) is a good initial target, because NRC but not f there is ARC when the exo devia-
it has large suppression controls for al I three figures. tion is manifest. (Refer to Chapter 11 for a discus-
As the patient makes the very small step vergences sion of treatment of XT with ARC.)
when fixating from one figure to the next, the sudes
are separated slowly n the BO direction (numbers Convergence Walk-Aways (T14.10)
showing in the mask ruler). The patient uses volun-
Split Vectograms and Tranaglyphs are particularly
tary convergence in attempting to maintain fusin
helpful for DE and BX patients, who often lose
with clearness and without any suppression (e.g.,
fusin as the fixation distance s increased. A good
Little Bo Peep losing her sheep). The initial emphasis
pair of targets is the Spirangle Vectogram, which is
s on the BO range, but eventually Bl demands are
large and has an appreciable stereopsis effect at far
intermittently introduced so that fusional vergence
distances (see Figure 13-11 b). The BO demand
can be strong n both directions.
should be increased maximally at near while the
When diplopia (break) occurs, the BO demand is
patient maintains fusin. When a good BO range is
reduced sufficiently to allow for recovery of fusin.
established, the patient s instructed to walk away
The patient contines to bifixate each target on the
from the target slowly while maintaining fusin with
Vectogram for at least 1 minute before an ncreased
clearness. The spiral figure should appear more in-
BO demand s given. Smoothness of disparation
depth as fixation distance increases. Furthermore,
requires the therapist to move each sude laterally
the vergence demand decreases (theoretically),
and simultaneously at an appropriately slow speed
which should make fusin easier for the patient. For
for the patient. Later in training, the patient can learn
example, 12A at 40 cm transales to only 6A at 80
to move the si des properly and at a faster rate com-
cm and only 3A at 160 cm. Exotropic patients who
mensurate with his or her ability to maintain fusin
previously could not bifixate at far are delighted to
during the disparation. The patient should learn to
realize that they can fuse at far: The visual feedback
perceive blur (f possible) and record this valu along
of stereopsis and monitoring of suppression tells
with breakpoint and recovery point. Each training
them so. This newly discovered skill builds confi-
period should last approximately 10 minutes. Vari-
dence and motivation to continu to achieve in
ous split Vectograms and Tranaglyphs can be used
visin therapy. Once the patient can master fusing
for nterest and for the special features offered on
at far with a small BO demand, the split targets are
some (e.g., the Spirangle, with its subtle stereopsis
separated further (sliding vergence) to train for an
and suppression clues; see Figure 13-11b).
ncreased fusional convergence range.
As progress is made, two pairs of split Vecto-
grams or Tranaglyphs can be used on a Dual
Polachrome Illuminated Trainer for vergence facil- Projected Base-Out Sudes (T14.11)
ty training. The top target can be a divergence As n T13.10 for eso deviations using an overhead
demand and the bottom, convergence. The goal for projector, the therapist can project split Vecto-
412 Chapter14
grams or Tranaglyphs with a BO demand for encouraged to maintain fusin. Blinking some-
fusional convergence training at far. In XT of the times helps to relax accommodation to the plae
DE and BX types, the targets are initially aligned to of the fusin targets.
the patient's subjective angle of deviation, a Bl set- The goal is for the patient to progress to cards
ting. This technique s ideal for training sliding ver- having higher step prism demands, up to card 12,
gence at far, due to the fusional glue of stereopsis. while perceiving all suppression clues. The thera-
Besides sliding vergence, step (using two pairs of pist or patient must remember to move the aper-
targets at the same viewing distance) and jump ture slider appropriately with each change of target
(altrnate near-far viewing) vergence training can so that the slider does not block the view of either
be used to build the range and facility of fusional eye. Using lose BO prisms, a prism bar, or flipper
convergence. prisms or lenses can extend the range on the
instrument if desired.
An effective jump vergence technique involves
Aperture-Rule Trainer
having the patient diverge the eyes and focus on a
(Single Aperture) (T14.12) far target over the top of the Aperture-Rule Trainer
The Aperture-Rule Trainer can be used as an n- and then converge to the targets seen through the
office and home training instrument in cases of Cl aperture (Figure 14-4). The back-and-forth fixations
and basic XP. The design of the nstrument was dis- should be as rapid as possible. The patient records
cussed in Chapter 13 (T13.13). A single aperture s the number of cycles achieved within 2 minutes
used to crate BO demands (Figure 14-3). The and s given instructions to repeat this routine at
patient looks at and fuses the pair of targets at the least five times daily. Suppression should be moni-
distance of 40 cm through the single aperture (.e., tored and broken, if it occurs, before the patient
chiastopic fusin). If there s difficulty fusing the contines with this jump technique.
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 Pencil Push-Ups and
so the patient can nitially fuse the pair of targets Push-Aways(T14.13)
even though they may appear blurred. With fusin, Pencil push-ups are probably the most frequently
the pointer s quickly withdrawn and the patient s assigned home training technique in clinical practice
Chapter14 413
today. This s a simple, convenient technique and s shake the pencil a bit to enliven the suppressed
very effective in cases of Cl, if performed properly. image before continuing. The technique is contin-
Patients of all ages can use this technique. Aside ued for a 10-minute period or for some other time
from advancing the NPC, it can be used to estab- interval that the doctor judges feasible. Smoothness
lished physiologic diplopia, build vergence facility and amplitude of vergence tracking, not necessarily
and stamina, and train accommodative skills. A speed, are trained. The goal is to train smooth ver-
drawback, however, s that patients often find the gence tracking with no break-and-join response
technique boring. Therefore, compliance suffers, along the way and to achieve an NPC of 5 cm or
particularly when this technique s assigned as the closer. The closest NPC achieved during the training
sol training routine; unfortunately, this happens too session should be noted and recorded each day.
often n clinical practice. Just as do athletes, visin An emphasis on pencil push-aways is recom-
training patients need variety n their exercise pro- mended in cases of DE XT or XP because the far
grams for both psychological and physiologic reasons. exo deviation is larger than the near. As progress is
To use this technique, a patient must have an made and fusin occurs beyond arm's length, a
NPC within arm's length. A pencil, with its point up, walk-away technique is appropriate. The pencil
s held at arm's length and is fixated bifoveally. The becomes the physiologic suppression control as
patient positions himself or herself such that when the patient walks away while maintaining fusin of
fusing the pencil, an object across the room (e.g., a the far target (e.g., a doorknob).
doorknob or, better yet, a small televisin screen) Convergence stamina can be mproved through
appears double as a normal physiologic diplopic an isometric exercise. The patient steadily fixates a
image. While maintaining a single image of the pencil placed just beyond the NPC for an assigned
pencil and monitoring physiologic diplopia of the period; we suggest 1-2 minutes per period. Again,
distant target, the patient slowly moves the pencil physiologic diplopia should be monitored in the
toward the nose until the pencil tip doubles. Push- background. This technique quickly builds gross
ing the pencil away to regain fusin, the patient convergence35 but often s associated with consid-
tracks the pencil back to arm's length again. If sup- erable eyestrain. Sufficient rest periods, perhaps 5-
pression occurs and one of the physiologic diplopic 10 minutes, are recommended between training
images disappears, the patient should blink and ntervals.
414 Chapter14
and comfort but without suppression. If suppression The Lifesaver card is particularly applicable for
occurs, the patient should blink his or her eyes as an patients with Cl, either XT or XP. Once chiastopic
antisuppression method. All four pairs of circles (the fusin s achieved and the patient can make step ver-
top being the most difficult) should be easily fused. gence movements on the card, tromboning can be
The patient should strive to ncrease the speed of step introduced to bu i Id gross convergence, much as with
vergence responses by moving from one pair to the the pencil push-up technique.This advanced variation
next, up and down the card. The prism demand on requires the patient to make step vergence eye move-
fusional convergence for any particular pair at any ments as he or she brings the card closer to the nose.
particular distance can be easily calculated using the Another good nearpoint target for chiastopic
Griffin decimeter rule (see Chapter 13). fusin are the Keystone Eccentric Circles, which are
416 Chapter 14
ocular accommodative rock (see Chapter 16). the criteria for very strong vergence facility given
Patients with Cl usually have little or no difficulty in Chapter 2 (i.e., more than 15 cycles per minute).
with this technique by the time this phase of therapy There are numerous rock techniques, but three
s introduced, because the AC/A ratio s low and exemplary ones that are particularly useful for
lenses have relatively little effect on the demand for treating exo deviations are presented here.
fusional vergence. In BX cases, however, the AC/A
ratio is normal, and patients with large exo devia- Televisin Trainer and Prisms (T14.16)
tions may have trouble fusing the target clearly The use of televisin trainers for antisuppression
when plus lenses are ntroduced. This difficulty usu- training (T12.8) s discussed in Chapter 12. This
ally is exaggerated in DE cases because of the technique applies for vergence rock training also,
higher-than-normal AC/A. In summary, T14.15 s although here the emphasis is on motor fusin
most necessary in DE cases, less so n BX, and least training to develop and improve fusional conver-
necessary n Cl cases. The therapeutic technique gence skills. This technique applies to farpoint
parallels that of T13.11 except that fusional conver- exo problems, as n BX and DE cases. A fortuitous
gence rather than divergence s emphasized. (Refer aspect of this technique is that central suppres-
to Chapter 13 for details of this technique and sion s monitored continuously as the patient
goals.) Because convergence s potentially stronger watches televisin over extensive periods. Step
than divergence and it s more easily trained and vergences can be trained with either lose or flip-
developed, most patients with exo deviations per prisms. Vergence facility can be trained effec-
quickly pass through this phase of therapy. tively during televisin commercial breaks.
Isometric training is especially appropriate by
Vergence Rock Techniques having the patient wear the mximum BO prism
Vergence rock training with flipper prisms can be demand that allows clear, single binocular visin.
conducted n cases of exo deviation in a manner Greater BO prism power can be worn in subse-
similar to that used for eso deviations (T13.12). quent training sessions f the patient can maintain
Step convergence should be emphasized more fusin and be reasonably comfortable. The goal s
than step divergence for patients with XT or XP, but to reach the mximum amount of prism that car
both should be trained. The training goal s to meet be worn for 15 minutes without suppression.
418 Chapter 14
Bar Reader with Prisms (T14.17) reinsert the prism, and so on. BO prism demands
Bar reading (T12.10) with BO prism rock is espe- are emphasized, although Bl prism demands are
cially helpful in Cl cases, because training is done at eventually incorporated into the training routine.
near (see Figure 10-20). However, the technique can The training goal in step vergence is 15 cycles per
be used effectively for any type of exo deviation as minute using 4A Bl and 8A BO. (See the criteria for
long as there is nearpoint fusin. It is a demanding very strong vergence in Chapter 2.)
exercise that is often given in the final stages of train- For jump vergence training, have the patient
ing and as a retainer exercise. Step vergence training alternately fixate from the penlight to the pencil.
is conducted by having the patient alternately The goal is to maximize the number of near-far fix-
change the prism from Bl to BO at the end of each ations in 1 minute with recoveries of clear, single,
line. If suppression occurs, the patient can blink his binocular visin without suppression.
or her eyes, increase illumination, and move closer
to the page. Reading in this manner is continued for Pola-Mirror Vergence
a 10-minute period. With practice, patients can Techniques(T14.19)
learn to read passages for meaning without thinking
Training with the Pola-Mirror was discussed in Chap-
about sensory or motor fusin. The prism amount
ter 12 as an antisuppression technique (TI 2.9) and is
can be increased each week as needed.
shown in Figure 12-10. Because this type of training
Effective isometric training is performed when
monitors foveal suppression, vergence training can
the patient wears the mximum amount of BO
be done while bifixation is being ensured. In Cl
prism power for periods of at least 10 minutes. The
cases, the technique involves push-ups with the
goal is clear, single, comfortable binocular visin
Pola-Mirror to train fusional convergence. The
without suppression.
patient is instructed to hold the mirror at arm's length
and to.move it slowly closer to approximately 5 cm.
Framing and Prisms (TI 4.18)
The patient is to see both eyes simultaneously. If one
An excellent vergence rock technique for farpoint eye darkens, indicating suppression, the patient is to
exo problems is framing with prisms. This is similar blink that eye and pay attention to it using mental
to bar reading for nearpoint training and is espe- effort to break the suppression. The intermedate goal
cially applicable to BX and DE cases. The patient is is to be able to see both eyes at all times from a
instructed to look at an object (e.g., a penlight range of 75 cm (note doubling of image distance by
from across the room). Have the patient hold a mirror [.e., 1.5-m image distance]) to approximately
pencil (or a bright red pointer stick) in the upright 10 cm. A final goal in Cl cases can be to master this
position in the midline, approximately 40 cm away technique while wearing 20A BO prisms over the
from his or her face. As the patient bifixates the polarizing filters during tromboning of the mirror.
penlight, he or she looks for the diplopic images of In cases of BX and DE, the patient performs the
the pencil. The patient then changes fixation to the described technique but emphasis is on push-
pencil tip and tries to be aware of the diplopic aways, because the fusional convergence demand
images of the penlight. When this process of is greater at far. Training can begin at a near dis-
awareness of physiologic diplopia is completed, tance, and the mirror then is slowly moved farther
the patient looks at the distant penlight and frames away (or the patient walks away), to at least 75 cm
it symmetrically with the diplopic images of the (i.e., 1.5-m image distance). By adding BO prism,
pencil. (Refer to the discussion on physiologic the fusional convergence demand is increased even
diplopia in Chapter 1.) The two images of the pen- more. The patient should practice this technique for
cil serve as peripheral suppression clues. If central 5-minute periods at least twice daily. The goal for
suppression clues are desired, targets such as Vec- the BX or DE patient is to achieve fusin continu-
tograms, Tranaglyphs, televisin trainers, and Root ously without suppression during push-aways.
Rings can be bifixated at far while being framed by
the pencil images (Figure 14-9).
Step vergence training with framing is carried Computerizad Convergence
out by having the patient place a lose prism Training (T14.20)
before an eye, achieve fusin of the fixation target Computerized visin therapy programs for exo
with framing, remove the prism, recover fusin, deviations are founded on the same principies as
Chapter 14 419
xr
^r>>
are those for eso deviations (T13.16). Such pro- puterized programs for improving fusional conver-
grams provide excellent training techniques for gence ranges, facility, and stamina.
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 CASE MANAGEMENT
features of computerized programs. We recom - AND EXAMPLES
mend such programs because of patient interest
and the motivation they stimulate. Particularly fas- Divergente Excess Exotropia
cinating s Computer Orthoptics by Dr. Cooper, Management Principies
which incorporates high-speed liquid crystal filters True DE XT and XP are characterized by a farpoint
for mutual cancellation of targets for the right and deviation that is substantially larger than at near.
left eye (see Appendix J and discussion in Chapter These patients present with farpoint problems (e.g.,
16). Most of the training techniques for patients asthenopia, diplopia, a cosmetic deviation) and
with XT and XP can be accomplished with com - often show normal fusional skills at near. DE usu-
420 Chapter14
ally s caused by an abnormally high AC/A ratio at far,25'37 and vergence rock techniques (TI 4.16).
with nadequate fusional convergence at far. It is the Push-away (T14.13) and walk-away (T14.10) tech-
least prevalent type of XT, although many exotropic niques should be emphasized to increase the ranges
patients initially appear to have DE.34 A prolonged of sensory and motor fusin at far distances.
cover test often reveis an ncreased nearpoint exo Successful management of DE patients with a
deviation, indicating a simulated rather than a true very high AC/A ratio or a large deviation at far s
DE.10 difficult with minus adds, even when visin train-
Our visin therapy approach in DE cases ing s included. Suppression at far can quickly
nvolves fully correcting any significant refractive recur, and the patient can relapse into XT. When
error, prescribing an appropriate minus add to help the patient looks up to the ceiling or sky, which s
control the far deviation, and initiating a vigorous lacking in strong fusional stimuli, the deviation
visin training program. The effect of minus-addi- tends to become manifest. Dissociation can also
tion lenses can be remarkable, as the AC/A ratio is occur when the patient moves from a dimly lit
high. For example, a patient with a 60-mm inter- space to a bright rea. Many exotropic individuis
pupillary distance with 20 A of intermittent XT at 6 tend to be dazzled and often cise one eye, break-
m and 10A XP at 40 cm has a calculated AC/A ratio ing fusin (see discussion in Chapter 7 in the sec-
of 10/1; the gradient is usually lower (e.g., 7/1). tion Primary Comitant Exotropia). In those patients
(Refer to Chapter 3.) This high AC/A ratio implies who do not respond to the combination of minus
that for every diopter of minus-lens addition that s adds and visin training or who demnstrate fre-
worn, the exo deviation is reduced by approxi- quent relapses, strabismus surgery (such as a bilat-
mately 7A. Therefore, a -1.00-D addition would eral lateral rectus recession) may be required for
cause the deviation at far to be reduced to approx- successful management.
imately 13A exo and to 3A exo at near, and a -2.00-D In most cases of intermittent XT of the DE type,
addition to approximately 6 A exo at far and 4A eso completion of visin therapy usually takes from 2 to
at near. Of course, these are merely theoretical 4 months. These cases can often be managed on a
vales, as patients do not always respond to the home training basis with weekly office testing and
addition lenses in a mechanical way. The clinician training visits. Bifocals (plus-adds) often are benefi-
must always observe and measure how the patient cial and may be prescribed at some time during
responds to minus-addition lenses at far and near therapy. The efficacy of bifocals n cases of DE is
before a lens prescription is written. In this case attributable to the fact that isometric fusional con-
example, the prescription of a -1.50-D add, n sin- vergence s trained at near. Also, the near and far
gle visin form, might be the best choice; it may magnitudes of exo deviation can be equalized. After
provide adequate control of the far deviation, dismissal criteria are met, a good retainer exercise is
reducing it to approximately 10A exo. The near the televisin trainer with prism (T14.16), because it
deviation with the -1.50-D add should be cise to monitors for suppression and trains the reflex
ortho. This approach possibly avoids the need for a aspects of fusional vergence at far. Thirty minutes
plus-add bifocal prescription for near viewing that per week of televisin watching with prism rock
would otherwise be needed if a minus add of during commercial intervals usually is sufficient to
higher power were prescribed. prevent regression of trained binocular skills.
The emphasis of the visin training is to break
suppression, often found at far, and to extend the Case Example
fusional vergence ranges at al I viewing distances. If This case report is provided courtesy of Dr. Janice
fusin cannot be quickly established at the farpoint Scharre of the Illinois College of Optometry, Chi-
with a minus add, a half-patch occluder to allow cago. Only a brief summary s presented here to
only nearpoint viewing must be worn until this s exemplify visin training in a case of DE XT.
achieved. Magic Tape (by 3M) or similar material A 10-year-old female patient was referred because
over the top half of one spectacle lens s a conve- of an occasional outward eye turn, occurring more
nient and effective method. Specific training tech- often at far. The time of onset was unknown, but she
niques that we have found particularly effective in had had t "for a while." Her only symptom was
DE cases include voluntary convergence (T14.1), occasional diplopia. She had been prescribed a
Brock string and beads at 3 m (T14.5), Vectograms patch by the referring doctor 6 weeks previously and
and Tranaglyphs (T14.9) using wide-field stimulation was wearing spectacles with constant patching of
Chapter14 421
her right eye. The patient's and the family's eye and PRA, -2.50), and amplitudes increased to 15 D in
health histories were unremarkable. There was no each eye. Good fusin was found at far and near
history of eye surgery, and the patient was doing well without suppression by Worth dots. Stereopsis
in school. mproved to 50 seconds of are. Because a trial
Pertinent clinical findings were as follows: frame refraction yielded more cylinder correction
than previously, new lenses were prescribed:
Habitual lenses (2 years od)
+
OD:+0.25-2.75x180 20/30 OD:+0.50-3.00x010 20/25
OS: +1.00-2.50x140 20/30 OS:+1.00-3.25x160 20/25
Refraction
+3 Another seven office visits with home training
OD:+0 .25-2 .25x015 20/30
+2 were prescribed and completed with the following
OS: +1.00-2.50x155 20/30
improvements: The patient was exophoric: 14 A at
Cycloplegic and manifest refractions were not sig- far, 6A at near. Fusional vergence ranges were nor-
nificantly different. mal: Bl A/18/10, BO 14/26/8 at far; Bl 14/16/10,
The binocular visin evaluation indicated a com- BO 30/40/14 at near. The NPC measured to the
itant, ntermittent, alternating, XT of 20A at far and nose and stereopsis improved to 30 seconds of are.
10A XP at near. The Worth four-dot test showed good The refractive findings were stable.
fusin at near but i ntermittent suppression OS at far. On the basis of the results of therapy, the patient
Fusional vergences measured as follows: Bl A78/2, was dismissed as cured. Retainer exercises were
BO A/10/4 at far and, at near, B110/12/10, BO A/10/ prescribed using eccentric circles and flipper lenses
4. The monocular accommodative amplitudes were every other day for approximately 10 minutes. A 6-
reduced for the patient's age (OD, 9.00; OS, 9.00), month progress evaluation was scheduled.
as was the relative accommodation (negative At the progress evaluation 6 months later, the
[NRA], +1.00; positive [PRA], -1.00). The NPC was patient reported no symptoms, and all clinical find-
normal (8 cm), but stereopsis appeared slightly ings remained normal. The visual acuity of the right
reduced (70 seconds of are on Randot). Eye health eye had increased to 20/20 but remained 20/25 in the
examination proved unremarkable. left. The conclusin was that this patient's DE XT had
The diagnosis was modrate astigmatism with pos- been successfully treated using visin training and
sible slight meridional amblyopia oculus uniter (OU), that meridional amblyopia was significantly reduced
DE XT, normal correspondence, suppression at far, by using visin training and corrective lenses.
slightly reduced stereopsis, and slight accommoda-
tive nsufficiency.
Vision therapy n the office and at home during Basic Exotropia
the first four weekly visits emphasized accommo- Management Principies
dative training with minus lenses and a Hart Chart, Patients with basic XT (the normal AC/A type) tend
vergence training with pencil push-ups and push- to have the largest angles of deviation and the high-
aways, Brock string and beads, and the three-dot est prevalence of constant deviations, although the
card. Accommodative skills had improved. By the majority are i ntermittent. Most BX patients have an
fifth visit, after Vectograms, the Aperture-Rule ntermittent strabismus at near and a constant stra-
Trainer, the Lifesaver card, and Tranaglyphs had bismus at far, as in DE cases. Exotropes, n general,
been ntroduced, the patient was able to appreci- have a better prognosis for a functional cure than do
ate SILO and converge 18A BO and recover 9A BO esotropes but, as in esotropa, constancy of the devi-
at nearpoint. Accommodative skills had also ation s a major consideraron (a 30% factor) in pre-
improved. By the seventh visit, she was able to dicting successful outcome.7
perform chiastopic fusin walk-aways with large Our approach to therapy n cases of constant XT,
eccentric circles and projected Vectograms. whether associated with NRC or ARC, is to attempt
The training results after week 7 indicated signif- to convert the constant deviation into an intermit-
icant mprovement in most binocular findings. No tent deviation at near distances as soon as possi-
strabismus was found at near or far. Fusional ver- ble.38 This step assumes that amblyopia is not
gences had increased: Bl A/14/12; BO 8/10/8 at present or has been successfully treated. As dis-
far, and Bl 14/16/8, BO 18/30/18 at near. The rela- cussed previously, we train for fusin at near using
tive accommodation was normal (NRA, +2.25; gross convergence (T11.13) and voluntary conver-
422 Chapter14
gence techniques (T14.1). If this training contines XP and the section on management principies for
for three or four in-office sessions without success, DE XT. At this point, the BX patient can be treated
we resort to more traditional techniques of build- in the same way, for training purposes, as is a DE
ing convergence on the major amblyoscope patient with fusin at near and strabismus at far.
(T14.2). If, however, the patient is successful in Basic XP is far more prevalent than is basic XT.
accomplishing fusin at near, even with great effort These patients are usually symptomatic and present
for short periods, we continu with open environ- with a modrate to large exo deviation at far and
ment training methods at near, such as Brock string near, deficient fusional convergence and, often, an
and beads (T14.5), Bernell Mirror Stereoscope associated accommodative deficiency. Bl prism can
(T14.4), and Vectograms (T14.9). be prescribed for symptomatic relief in these cases,
An attempt is made to find some satisfactory using as a basis one of several standard clinical cri-
combination of Bl prism and minus-add power to teria: Sheard's criterion, clinical wisdom (one-third
establish fusin at some distance, often at near. If the angle of deviation), or associated phoria as
the patient has adequate accommodative ski lis (or measured on fixation disparity testings. (Refer to
if they can be trained quickly), the effects of minus- Chapter 3 on heterophoria case analysis.) We often
add lenses are evaluated for a 1- or 2-week trial recommend a 6- to 8-week course in visin train-
period of wear. The minus-add is often a good ing for symptomatic XP, mostly home-based.
stimulus to initiate fusiona! vergence eye move- Within this time frame, functional deficiencies of
ments, even if the angle of deviation is not signifi- fusional vergence and accommodation usually
cantly reduced. With children younger than age respond sufficiently to a consistent, well-designed
10, up to a -3.00-D add should be tried; these training program of approximately 30 minutes of
youngsters can usually learn to tolrate the accom- home training per day. The specifics of the visin
modative demand within 1 or 2 weeks. Older chil- training program for basic XP are similar to those
dren and young adults often benefit with minus described previously for DE XP and for Cl XP
adds, but lesser powers are more tolerable. It bears (described in the next section).
repeating that if sensory fusin cannot be achieved
at a particular distance by any means, the patient Case Example
must wear a patch on one eye for that fixation dis- This example of visin therapy for basic XT was
tance. While in a visin therapy program, the contributed by Dr. Garth N. Christenson, an opto-
patient is not allowed to view the world in his or metric practitioner, of Hudson, Wisconsin. A 7-year-
her strabismic condition. old boy was evaluated for binocular anomalies
Auditory biofeedback is a promising alternative because his parents had noticed an occasional
technique for achieving bifoveal alignment of the outward turning of an eye. The eye turn began 2
eyes in XT. Goldrich 39 reported his experience years previously, but it had been worsening. Case
with 12 exotropic subjects and a training protocol history was otherwise unremarkable, and the
that he developed. The intermittent strabismics patient reported no such symptoms as blurred
quickly achieved alignment at all distances and visin, diplopia, or asthenopia. Subjective refrac-
built adequate fusional convergence using this tion and acuities were as follows:
technique, whereas the constant exotropes had
mixed results. The suggested advantages of bio- OD: +0.50 DS 20/20 (6/6)
feedback therapy were shorter treatment time, OS: +0.50 DS 20/20 (6/6)
elimination of lengthy home training exercises, Hirschberg testing was O mm OD and +1 mm
and enhanced patient motivation. Auditory bio- OS, suggesting 22A XT of the left eye. Cover testing
feedback instrumentation, unfortunately, is not at far indicated constant, alternating (right eye pre-
readily available, although computerized programs ferred for fixation) XT of 15A and, at near, intermit-
will probably become available. tent (strabismus approximately 10% of the time),
If the patient presents with fusin at near or it alternating XT of 15A. The deviation was the same
can be established quickly with optics and gross in all nine diagnostic fields of gaze, indicating
convergence techniques, the prognosis for func- comitancy. The patient had poor pursuit and sac-
tional cure with visin therapy is good (at least cadic eye movements. Correspondence was tested
70%)7 Training proceeds as described in the earlier with Bagolini striated lenses, the major amblyo-
sections on the visin therapy sequence for XT and scope, and Hering-Bielschowsky afterimages, and
Chapter14 423
NRC was found on all tests. The patient had sup- circles at far and near, Lifesaver card, and lens rock
pression at far on the Worth dot test but good with flippers. The patient was instructed to do
fusin at near. Stereopsis at near on a contoured home training twice weekly and to return for a
test was 140 seconds of are. Fusional vergence progress evaluation in 3 months.
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 Convergence
and 20 cm to recovery. Monocular accommoda- Insufficiency Exophoria
tion was normal, but binocular accommodative Management Principies
facility could not be tested because of suppression Cl exo deviation refers to a prevalent condition
when plus lenses were introduced. characterized by a low AC/A ratio, a larger exo
These findings were discussed with the child's deviation at near than atfar, deficient fusiona! con-
parents, and recommendations for visin training vergence and, often, a reduced NPC (beyond 8
were made. The possibility of surgery was dis- cm). Frequently, there exists an associated accom-
cussed but not recommended owing to the good modative deficiency. Exophoric Cl is far more
prognosis for cure with visin training. The esti- prevalent than s exotropic Cl, but the manage-
mated treatment time was 20 to 25 office visits ment principies are essentially the same. Between
along with home training. 3% and 5% of the young adult population was
The first 8 weeks of visin therapy consisted of reported for a prevalence of Cl.40 Patients usually
gross convergence training (pencil push-ups, Brock present with a slight XP at far and a larger XP and,
string and beads, and three-dot card), accommo- occasionally, XT at 40 cm. Visual symptoms
dative training (various techniques using a Hart include headaches, occasional diplopia, ntermit-
Chart), and a variety of saccadic and pursuit train- tent blurring, eyestrain, tired eyes, loss of concen-
ing techniques. The next phase involved the fol- tration, and sleepiness, among others. Cl has also
lowing training techniques: been found to be more prevalent among students
with reading problems.8 Differential diagnosis
1. Sliding vergence techniques, including
requires distinguishing etiologies other than a low
Vectograms emphasizing BO demands and
AC/A ratio and deficient fusional convergence,
perception of SILO, Bernell Mirror Stereo-
which account for the gross Cl, as indicated by a
scope, and major amblyoscope
reduced NPC. These other neuromuscular condi-
2. Step vergences, including Vectograms, Ber
tions include accommodative insufficiency result-
nell Mirror Stereoscope, major amblyo
ing in pseudo-Cl and convergence weakness due
scope, and televisin trainer (with -2.00-D
to neurologic paresis or paralysis. (Another possi-
overcorrection to faciltate fusin at far)
ble cause of a remote NPC is convergence excess
3. Chiastopic fusin with Lifesaver cards and
esotropa; at near distance, the esophoria increases
Keystone Eccentric Circles (near and far)
beyond the limits of fusiona! divergence, resulting
with -2.00-D overcorrection at far when
in a "break.")
needed
Vision training has been the traditional therapy
4. Accommodative rock, monocular and bin
for Cl. In most cases, it can be considered to be an
ocular
effective and practical approach, and training time
5. Fusional high-level vergence techniques
is brief. Grisham 8 evaluated the results of training
(e.g., Delta Series Biopter Cards for far BO
in Cl cases reported between 1940 and 1984. With
recoveries, projected vectographic slides,
a datbase of 1,931 cases, the cure rate was 72%,
and accommodative rock combined with
the improvement rate 19%, and the failure rate
vectographic Bl and BO demands)
9%. Daum 41 analyzed the results in 110 Cl
After 15 weeks of office visits and home train- patients and presented the clinical factors that cor-
ing, the patient was cured of XT. There were nor- related with success. Most of the training in this
mal vergence ranges, and oculomotor deficiencies patient series was completed at home. The average
were abated, as were accommodative infacility, training time was 4.2 weeks. The average age of
suppression, and poor stereopsis. At the time of the patients was 20 years, ranging from 2 to 46
dismissal, the patient was prescribed a home years. Adult patients were mildly associated with
maintenance therapy program including eccentric shorter periods of treatmen, presumably due to
424 Chapter14
maturity of the patients and increased compliance Wick's results were confirmed by Cohn and
with the training program. Over the course of train- Soden.44 A patient's age should not be the deter-
ing, there were statistically and clinically signifi- mining factor regarding the application of visin
cant changes n the NPC, al I the positive fusional training in cases of exophoric presbyopia with Cl.
convergence vales (blurpoint, breakpoint, and A visin training program for Cl can proceed as
recovery) at far and near, the negative fusional follows: As always, therapy starts with the correc-
divergence blurpoint at near, and the amplitude of tion of any significant refractive error. Even correc-
accommodation. It has also been demonstrated tion of low amounts of hyperop ia can be
that asthenopic symptoms are reduced in response beneficial, as many Cl patients have an associated
to the training of fusional vergence in Cl cases.42 accommodative deficiency. Many cases can be
Another condition similar to Cl is presbyopic XP. improved by prescribing spectacles for reading
It is well-known that presbyopic patients show an (+1.00-D add) and Bl prism for the convergence
increase in the nearpoint XP as the power of the deficiency, but we usually reserve this approach
reading add is increased over the years. (The for those patients who cannot or will not partic-
increase is less than would be predicted simply by pate in a short visin training program.
the decrease of accommodative convergence with If the patient does have accommodative defi-
accommodative response.) Nevertheless, presby- ciency, training accommodative skills becomes the
opic patients often manifest an increased XP at initial goal of the program. Monocular and binocu-
near, a receding NPC, deficient fusional vergence lar exercises that are appropriate for accommoda-
response, and increased fatigue and ocular dis- tive training include accommodative tromboning
comfort if they continu with reading or other (T16.21), jump focus (T16.22), and lens rock
demanding nearpoint activities for extended peri- (T16.23), described in Chapter 16. Accommoda-
ods. Some clinicians have recommended Bl prism tive facility for each eye can often be maximized
in the form of single visin reading glasses or within the first 3 weeks of a training program. Bin-
through the bifocal add, in an attempt to increase ocular accommodative rock (T14.15) is introduced
patient comfort and efficiency. This is a valid and after the monocular phase of training has been
useful approach; however, relieving prisms do not completed, to help increase both accommodative
always give satisfactory results, and visin training and vergence facilities.
remains an alternative treatment option. There The next recommended goal in training is to
appears to be a clinical bias against applying establish physiologic diplopia while building vol-
visin training with elderly patients, on the pre- untary and gross convergence. This goal can be
sumption that the training will not be successful or accomplished by using, primarily, three tech-
acceptable to the patient. One study suggesting niques: the Brock string and beads (T14.5), pencil
that this bias is unjustified carne from Wick,43 who push-ups (T14.13), and the three-dot card (T14.6).
attempted a visin training program with 191 pres- The specific training goal can be to build an NPC
byopes, ages 45 to 89 years, having asthenopic of 5 cm, with smooth and accurate vergence and
symptoms associated with Cl and presbyopic XP. accommodation at all distances and full awareness
The home-based program was 0.5 hour per day for of physiologic diplopia.
an average of fewer than 10 weeks. Home training The goal of enhancing central sensory and
was augmented with periodic office visits. The motor fusin can be achieved using many tech-
longest training program lasted 15 weeks. Using niques. Appropriate instruments and tatgets are
well-defined and rigorous criteria for success, a designed to train vergence ranges, monitor for sup-
93% cure rate was reported immediately after the pression, and enhance stereopsis. Clinicians and
training program. A 3-month follow-up examina- visin therapists are encouraged to explore their
tion indicated that 48% of the previously cured own creativity in designing and combining various
patients needed some additional training, particu- methods. Some of the standard techniques that we
larly those patients older than 75 years. This study recommend for this purpose can also improve bin-
indicates that age is a small factor in successful ocular efficiency (i.e., speed, accuracy, integration,
training only for patients in their late presbyopic and stamina of accommodation and vergence). We
years. This factor is of minor clinical consequence find it efficacious to intgrate vergence range train-
because maintaining a successful result merely ing with techniques for binocular efficiency. Train-
requires periodic reinforcement of learned skills. ing techniques should include sliding, tromboning,
Chapter14 425
step, jump, and isometric vergences. We tend to gory mmediately after training. Those who had
emphasize phasic (.e., step and jump) techniques, been released as cured maintained the same result
which are reported to be slightly more effective.45 after 6 months and 2 years. Of those patients n the
Isometric techniques also have the advantage of partially cured group, 79% remained asymptomatic
being efficientthat is, they produce results in a after 6 months, but only 11% were asymptomatic
relatively short period.35 Some of our favorite tech- after 2 years. There was also a slow decompensation
niques in Cl cases are Vectograms and Tranaglyphs of clinical findings. The failure group received no
(T14.9), the Aperture-Rule Trainer (T14.12), chias- symptomatic relief, and even the improved conver-
topic fusin (T14.14), binocular accommodative gence skills were not maintained 6 months after
rock (TI 4.15), and bar reading with prisms therapy. This report illustrated the need to achieve a
(T14.17). Even though, in Cl cases, the initial train- complete functional cure f regression of skills and
ing emphasis is placed on convergence skills, reappearance of symptoms are to be avoided.
divergence should not be ignored. We suggest the Grisham et al.6nvestigated the persistence of
ratio of two-thirds convergence training to one- the vergence training effect in cases of XP at near
third divergence training, to ensure that the entire and deficient fusional convergence. These research-
zone of clear, single, comfortable binocular visin ers used the vergence tracking rate, objectively
is being expanded. determined from eye movement recordings, as an
The specific training goals and relase criteria ndex of vergence performance (Figure 14-10). Four
are very strong convergence and divergence Cl subjects received standard visin training for
ranges free of suppression, far and near (see Chap- vergence deficiencies, and two served as no-inter-
ter 2). An easy-to-remember clinical guideline for vention controls, but tracking rates were monitored
relase criteria is 20/30/20 (blurpoint/breakpoint/ n al I. The vergence tracking rate of each trained
recovery) for convergence and divergence at near subject improved to normal levis within a period
and for convergence at far. There should also be of 5-8 weeks; the controls showed no significant
normal stereopsis (at least 40 seconds of are), good improvement. During the 6- to 9-month post-train-
NPC (5 cm or closer), and a normal fixation dispar- ing period, three of the four trained subjects
ity curve with no measurable associated phoria on showed no significant regression in vergence track-
a nearpoint test with a central fusin lock, such as ing rate; these were the subjects who met all the
the Bernell test or Saladin Card. Before being relase criteria for dismissal from the training pro-
released, the patient should be free of symptoms gram. However, one subject showed a slow linear
and visual avoidance behaviors. We recommend regression of vergence tracking rate over the 9
training for at least 1 week after symptoms have months, almost to the pretraining level. That subject
disappeared, to reinforce the newly learned skills. had discontinued the training prematurely before
Most Cl exophoric patients can achieve these goals all relase criteria were met. He also reported a
within 6-8 weeks in a home training program with gradual recurrence of visual symptoms in associa-
periodic office visits; Cl exotropes typically require tion with reading activities and later was referred
a longer training period, perhaps 8-10 weeks or for further visin training. This study provides
more, but are managed n essentially the same objective evidence supporting the validity of ver-
way. We suggest office visits once weekly to moni- gence training and demonstrates good short-term
tor the patient's progress, to prescribe and teach retention of trained skills if al! relase criteria are
new training techniques and, importantly, to con- achieved.
tinu motivating the patient. Most individuis Although regression is not expected in most
undergoing any type of training program need cases, a maintenance home training technique
encouragement and reinforcement; visin training should be assigned after visin therapy. At the
is no exception. least, the patient can do self-monitoring for regres-
After a successful training program for Cl is com- sion and return for "booster" training f needed. !n
pleted, such that al I the relase criteria have been cases of Cl, we often recommend pencil push-ups
met, little regression of skills s expected. This with physiologic diplopia awareness (T14.13) for
expectation is based on our clinical experience with 20 minutes every 2 weeks as a retainer exercise.
these cases and two studies that have addressed the Bar reading with prisms (T14.17) s another good
issue. Pantano36 compared the long-term results of option. We have not seen regression of skills or
207 Cl patients on the basis of their success cate- recurrence of symptoms over several years in Cl
426 Chapter14
2.5
1.5
CE ~j Abnormai
=3 O Control BA
J Subjects
I.O
SM-l
Experimental
Subjects
0.5
05
2
2
J 10
O 2 4 6 8 IO
WEEKS WEEKS
patientseven presbyopic exophoreswhen they far ndicated normal stereoacuity. Fusional vergence
maintain this training schedule. Many patients ranges were as follows: Bl 6/4 at 6 m, 10/16/14 at 40
accept this simple periodic exercise as a standard cm; and BO A/10/4 at 6 m, A/8/4 at 40 cm. The NRA
part oftheir general health maintenance. was +1.25 and the PRA -4.00. Monocular accom-
Case Example modative facility was normal, but the patient had dif-
The following case of XP with Cl also was contrib- ficulty with binocular facility when plus lenses were
uted by Dr. Garth N. Christenson, an optometric ntroduced. A steep slope of the forced vergence
practitioner, of Hudson, Wisconsin. A 16-year-old curve was found on fixation disparity testing with the
female patient presented with reports of frontal head- Disparometer.
aches after reading for approximately an hour, blur- These clinical data ndicated the diagnosis of Cl
ring of words, great difficulty concentrating during (principally based on the exo deviation at near, low
reading, and problems focusing from far to near. Her AC/A ratio, decreased fusiona! convergence, low
health history was unremarkable. The refraction indi- NRA, and poor binocular accommodative facility
cated only a slight amount of hyperopic astigmatism with plus lenses). The diagnosis was discussed with
that was considered to be clinically insignificant. The the patient, and she became aware of the nature of
uncorrected visual acuities were 20/15 OD, OS, and her visin problems. She was informed that visin
OU. Pursuits and saccades were full and normal with training provided the best choice for relieving her
comitancy. Cover testing indicated orthophoria at 6 symptoms but that she would have to decide
m and 7A XP at 40 cm. NPC was 5 cm to breakpoint, whether she would be willing to devote the time
and recovery was 7 cm; however, the breakpoint was and effort necessary for successful results. The
8 cm and recovery 10 cm after five attempts (indicat- patient said she was willing to do so and planned
ing a possible problem with vergence stamina). There on approximately 15 weekly office visits n con-
was good fusin on the Worth four-dot test. The Ran- junction with daily home training.
dot Stereo test at near and the Vectographic Slide at
Chapter14 427
Vision training proceeded for 10 weeks and 5. Cooper J, Feldman J. Operant conditioning of fusiona!
included the following approaches: convergence ranges using random dot stereograms. Am J
Optom Phyisol Opt. 1980;57:205-213.
1. Gross convergence training to develop vol- 6. Grisham JD, Bowman MC, Owyang LA, Chan CL. Ver
untary convergence and awareness of phys- gence orthoptics; validity and persistence of the training
effect. Optom Vis Sci. 1991 ;68:441-451.
ologic diplopia.
7. Flom MC. Issues in the Clinical Management of Binocular
2. Increase sliding vergence blurpoint, break- Anomalies. In: Principies and Practica of Pediatric Optom-
point, and recovery ranges. etry. Rosenbloom AA, Morgan MW, eds. Philadelphia: Lip-
3. Improve step vergence skills. pincott; 1990:222.
4. Intgrate accommodative and vergence 8. Grisham JD. Visual therapy results for convergence insuf-
demands (BO plus-BI minus). Note that BO ficiency: a literature review. Am J Optom Physiol Opt.
1988;65:448-454.
and plus-add produce demand on fusional 9. Burian HM, Smith DR. Comparative measurement of
convergence, whereas Bl and minus add exodeviations at twenty and one hundred feet. Trans Am
produce demand on fusional divergence. Ophthalmol Soc. 1971;69:188-199.
5. Combine step (BI-BO) and jump (near-far) 10. Cooper EL, Leyman IA. The management of intermittent
vergences with versions to simlate real-life XT: a comparison of the results of surgical and nonsurgi-
cal treatment. Am OrthoptJ. 1977;27:61-67.
visual environment.
11. Jampolsky A, Flom MC, Weymouth FS, Moses LE. Unequal
Instrumentation such as the Bernell Mirror Stereo- corrected visual acuity as related to anisometropia. Arch
scope, Vectograms, flippers lenses, Brock string Ophthalmol. 1955;54:893-905.
12. Flom MC, Wick B. A Model for Treating Binocular Anom
and beads, and the three-dot card were used. alies. In: Pedatric Optometry. Rosenbloom AA, Morgan
At the time of dismissal, all visual symptoms had MW, eds. Philadelphia: Lippincott; 1990:246.
resolved. The patient was reading comfortably at 13. lacobucci IL, Archer SM, Giles CL. Children with XT
all times and was enthusiastic about relief of symp- responsive to spectacle correction of hyperopia. Am J
toms. Clnica! data were as follows: NPC to nose; Ophthalmol. 1993;116:79-83.
14. Jampolsky A. Ocular deviations. Int Ophthalmol Clin.
Bl at 6 m, 12/4; BO at 6 m, 20/44/40; Bl at 40 cm, 1964;4:567-701.
A/16/15; BO at 40 cm, 28/32/30; binocular 15. von Noorden GK. Binocular Vision and Ocular Motility,
accommodative facility, 20 cycles per minute; 6th ed. St. Louis: Mosby; 2002:359.
NRA, +2.25; fixation disparity curve, fat slope. A 16. Hardesty HH. Management of intermittent XT. Binocul
maintenance program for home visin training was V/s.1990;5:145-152.
17. Hiles DA, Davies GT, Costenbader FD. Long-term obser-
prescribed, and the patient was scheduled for a
vation on unoperated intermittent XT. Arch Ophthalmol.
progress evaluation in 3 months. The maintenance 1968;80:436-442.
program included techniques using the three-dot 18. Wick B. "Forced elimination" of anomalous retinal corre-
card, Lifesaver card for orthopic and chiastopic spondence in constant XT: a case report. Am J Optom
fusin rock, and eccentric circles to ensure large Physiol Opt. 1975;52:58-62.
19. Lie I, Opheim A. Long-term stability of prism correction
vergence ranges. The patient was instructed to per-
of heterophorics and heterotropics: a 5 year follow-up. J
form these techniques for approximately 15 min- Am Optom Assoc. 1990;61:491-498.
utes twice weekly. 20. Davies GT. Vertical Deviations Associated with Exodevia
tions. In: Symposium on Horizontal Ocular Deviations.
Manley DR, ed. St. Louis: Mosby; 1971:149.
21. Caltrider N, Jampolsky A. Overcorrecting minus lens ther
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chapter 15 / Management of Noncomitant Deviations,
Intractable Diplopia, and Nystagmus
Ratients who present with noncomitant deviations, cian mus go through the same differential diagnostic
diplopia, or nystagmus require a high level of pro- process as is used for an acquired deviation later in
fessional attention. These conditions can be har- life. There always exists the possibility that a disease
bingers of neurologa disease; careful differential process or injury has caused an extraocular muscle
diagnosis and therapeutic management are needed. palsy, and the etiology must be established and
Although it reviews some mportant diagnostic points treated, f possible. However, many restrictive condi-
of these conditions, this chapter emphasizes manage- tions affecting ocular motility, such as Duane retrac-
ment approaches and specific treatments. The reader tion syndrome and Brown syndrome, can and should
is referred to Chapter 4, which discusses testing pro- be recognized early. Although rare, noncomitant devi-
cedures for noncomitant deviations, and to Chapter ations do occur during the traumatic process of natu-
8, which elabrales on the differential diagnosis ral childbirth, but often the cause of infantile
and management of noncomitant deviations and noncomitant strabismus remains unknown. It should
nystagmus. also be remembered that infantile comitant esotropa
frequently is assocated with overactng inferior
oblique muscles occurring later for unknown reasons;
ths introduces a noncomitant vertical component to
INFANTILE NONCOMITANT
the strabismus as the child matures.
DEVIATIONS
Diagnosis Management
When an nfant s found to have a noncomitant devia- Management of each type of noncomitant strabismus
tion from birth or within the first year of life, the clini- depends on the specific condition, age of the patent
430 Chapter 15
CONTRACTURE
OF RMH LIKELY
RELAXATION
OFRMR
S T I M U L AT I O
N FIGURE 15-2Partial occlusion for relief of diplopia in cases of non-
EXCESSIVE
INNERVATION
comitancy. a. Occluder on temporal portion of spectacle lens in case
TO LMR WITH of right lateral rectus paresis, b. Base-out Fresnel prism when fusin
CONTRACTURE
LIKELY can be obtained on dextroversion in case of mild paresis.
power at the particular axis is recorded for a stra- For training at home, we have found the Mars-
bismic eye. For example, for a deviation of 8 A den ball technique (T16.14) to be effective. An
base-up and 18A BO of the left eye, the measure- afterimage placed on the fovea of the paretic eye
ment and prescription would be approximately can provide visual feedback to the patient as to
20A at 23 degrees oculus sinister (OS) (Figure 15-4). the accuracy of the pursuit eye movement as the
This information is given to the optical laboratory patient attempts to keep the afterimage on the
for fabrication of either a ground-in prism or a sin- swinging ball (T10.17). There are also severa!
gle Fresnel prism. appropriate saccadic training techniques (TI 6.1-
T16.12) for therapy in the affected field of gaze,
Ocular Calisthenics described in the next chapter. Playing various eye-
hand coordination games, such as Ping-Pong or
Physical therapy is recommended for paretic
computer games (T16.12), is effective and popular
extraocular muscles. Exercises designed to forc
with patients.
the paretic eye to move, particularly toward the
field of action of the affected muscle, may help in
restoring function and preventing contracture. Sensory and
Many pursuit and saccadic techniques discussed Motor Fusin Training
in Chapters 10 and 16 are appropriate here. Ini- The patient should be fusing as much of the time as
tially, the unaffected eye is occluded for monocu- possible after an acquired extraocular muscle pare-
lar pursuit training of the affected eye. (Refer to sis. The majority of patients have a history of good
Tables 16-5 and 16-6 for specific techniques.) binocular visin prior to the onset of noncomitancy.
1 2 10 15 20 25 30
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434 Chapter15
Sensory fusin training is usually unnecessary. The should try to continu this training process for a
expansin of the motor fusin range, however, s 10-minute period and then rest the eyes. Limita-
recommended in practically all cases of recent ori- tions of the fusin field n all affected directions
gin. Sliding, sometric, and small step vergence can often be eliminated or diminished in this man-
training techniques seem easier and more effective ner with repeated practice for 2 or 3 months.
than do jump (near-far) and tromboning techniques,
at ieast initially. In cases of sixth nerve paresis, we Double Maddox Torsin Training (T15.2)
have found the Bernell Mirror Stereoscope (T13.2), In cases of noncomitant vertical deviations, such
the Brewster Stereoscope (T13.3), and Vectograms as a superior oblique paresis, there s often an
(TI 3.8-13.10) to yield good training results. (See associated cyclotorsional component. Relatively
Appendix J for manufacturer information for trade few techniques, other than working on a major
products cited in this chapter.) The targets should amblyoscope, are available for training cyclover-
have as much stereopsis conten as possible to help gence. Wick3 described a home training technique
to expand the divergence ranges at near and far. In to expand the range of cyclovergence using two
cases of fourth nerve paresis, vertical prism com- Maddox rods. The patient views a bright small light
pensation often is required n combination with the through a hand-held Maddox rod placed before
foregoing techniques and two described subse- each eye. The axes of the streaks are rotated until
quently (i.e., fusin field expansin [T15.1] and their images are aligned and fused. Initially, fusin
double Maddox torsin training [T15.2]). should be established n the least affected field of
Erickson and Caloroso2 described a case of a gaze. The axes of the Maddox rods then are rotated
39-year-old woman to Ilstrate the use of prisms slowly as the patient attempts to maintain sensory
and visin training. The patient presented with and motor fusin. When fusin breaks and diplo-
reports of constant diplopia after her first bifocal pia of the streaks occurs, the Maddox rods are
correction and was found have an esotropa and a rotated back so that fusin can be regained. For a
noncomitant hyper deviation associated with a 10-minute period, the patient strives to increase
long-standing paresis of the superior oblique mus- the cyclofusional ranges, particularly of the com-
cle. A combination of compensating vertical prism pensating vergence (e.g., ncyclovergence n cases
and horizontal vergence training was used to re- of superior oblique paresis). As training progresses,
establish fusin and to resol ve the patient's symp- the fixation light s moved into the most affected
toms. Many of the specific training techniques field of gaze to mercase the challenge to the
described n Chapters 13, 14, and 16 are applica- patient. Isometric vergence training is also useful
ble n cases of noncomitant cyclovertical devia- in these cases.
tions when there s good potential for fusin.
After the waiting period, when the residual devia- are somewhat rare, but most clinicians will eventu-
tion n the primary position exceeds 15A esotropa, al ly be called on to manage or refer a case for
20A exotropia, or 12 A vertical strabismus and defintive treatment. Each etiology s discussed,
remains significantly noncomitant, extraocular mus- along with its therapeutic mplicatons.
cle surgery should be considered as a treatment In some individuis having a constant strabis-
option.5 Lesser degrees of deviation can often be mus in early childhood, ARC becomes adapted
successfully managed with a combination of com- permanently to a particular angle of deviation.
pensating prisms and visin training. Unlike most patients with ARC n whom this sen-
These patients often need cise follow-up care, sory adaptation shows considerable variability
regardless of whether an operation is required. (e.g., covariation), a few patients show little or no
There is usually some residual deviation that may variation in their angle of anomaly when the angle
present a fusin problem to the patient. Six-month of deviation changes for some reason later in life.
progress checks are realistic for many patients, but The strabismic angle may change during life for
each must be judged by resultant clinical features any number of reasons, and intractable diplopia
of the deviation. may occur due to cosmetic strabismus surgery,6
injury, disease, visin training (particularly inap-
propriate antisuppression training), growth, and
INTRACTABLE DPLOPIA idiopathic causes. Suppression is not deep n these
cases, so the change in the angle of deviation may
Diagnosis be accompanied by diplopia. We have seen cases
When a patient presents with double visin, the in which the diplopia s present oniy when the
clinician must discover the cause, because some patient's attention is directed toward the second
etiologies are life-threatening (e.g., a brain tumor). image or under certain testing conditions; other-
Several history questions should be asked: Is the wise, the second image s usually suspended from
diplopia monocular or binocular? Does t occur perception. In one case, testing revealed central
with or without spectacles? Is t constant or nter- horror fusionis; the images could not be fused n
mittent? Under what circumstances is it present? real space or n a major amblyoscope. The patient
Describe the time and type of onsetrapid or was reassured that the diplopia represented only a
gradual. What is the separation distance and direc- potential problem requiring no treatment at that
tion? Are there associated general health, neuro- time. The patient was counseled to continu to
logic problems, and ocular health signs and ignore the double image and not to look intention-
symptoms? The diagnosis often requires an accu- ally for it.
rate refraction and visual acuity assessment, a Some patients with early-onset strabismus expe-
complete ocular motor evaluation, and thorough rience "fixation switch diplopia."7'8 When these
visin and general health examination. patients fixate with the preferred eye, they have no
Successful management of intractable diplopia diplopia, due to suppression or ARC. When fixat-
presents a challenge to the clinician. This condition ing with the nonpreferred strabismic eye, however,
occurs when there s some insurmountable obsta- they notice diplopia. Fixation switch seems to
cle to sensory and motor fusin and a lack of sup- occur primarily in patients with good visual acuity
pression to prevent diplopia. Fusin may not be in the nonpreferred eye and in patients in whom
established by conventional therapeutic methods: patching of the dominant eye has occurred for an
refractive error correction, prism compensation, extended time, as in the treatment of amblyopia. If
visin training, or surgery. These methods for re- there s spontaneous altrnate fixation and the
establishing single, clear, and comfortable binocu- resulting diplopia is bothersome, the patient needs
lar visin should be tried or at least considered reassurance and treatment. Such patients can be
before other means are attempted to elimnate one taught to elimnate the diplopia by blinkng the
of the diplopic images. Intractable diplopia can nonpreferred eye to switch fixation back to the pre-
occur from severa! causes, such as (1) a change in ferred eye. If this simple measure is not sufficent,
Ihe angle of devation in a developmental strabis- the visin of the strabismic eye can be optically
mus associated with ARC; (2) nonfusible metamor- blurred to discourage fixation.9 A careful diagnosis
phopsia; (3) bilateral superior oblique palsy; and is necessary before treating such patents on a
(4) sensory fusin disruption syndrome. These cases symptomatic basis. It s possible that when patients
436 Chapter15
switch fixation to the nonpreferred eye, causing major amblyoscope set to the subjective angle of
diplopia, they may have changed to NRC localiza- deviation with the torsional component included.
tion.10 If this s so, fusin may ndeed be possible, If the condition does not resolve within 8 months
and a graded occlusion method could be used to of the time of onset, surgery often s required.
establish normal fusin (see Chapter 11). Sometimes, however, itwill be necessary to imple-
Metamorphopsia refers to distortions of an ment a permanent management scheme for intrac-
image in one or both eyes, but our concern here is table diplopia. In this event, in which acuities are
a distortion great enough to present an obstacle to usually normal and equal, a monovision solution
sensory fusin. Some patients have these distor- may be attempted.
tions due to macular damage originating from a Closed head trauma followed by coma can result
number of sources (e.g., age-related maculopathy, in a total or partial loss of the capacity for sensory
diabetic retinopathy, solar or lser lesions, and and motor fusin. This condition is termed sensory
central serous retinopathy). In these cases, the fusin disruption syndrome.uWorth13 first pro-
peripheral fields usually remain fused, but the posed the dea of a "central fusin faculty"; several
patient may notice diplopia centrally. Diagnosis rare cases reported n the literature12'14 appear to
can be established by having such patients draw support this notion, and they also suggest a mid-
their perception of an Amsler grid pattern while brain site for a sensory fusin centn Most patients
fixating with the affected eye. Fusin training can with this affliction and a history of normal binocu-
be attempted in cases of central metamorphopsia lar visin experience orthotropia after "successful"
but often without success. We have found the most surgery or prism compensation, but they still show
acceptable solution n these cases to be central no ability to join the two overlapping images. Lon-
field occlusion, described in the next section. don and Scott,12 however, described one 17-year-
Extreme aniseikonia s another form of visual old patient who eventually regained fusin after a
field distortion that may preclude sensory fusin. bicycle accident that rendered her comatose for 3
Because this condition usually is associated with weeks. These practitioners neutralized the esotro-
large degrees of anisometropia and occurs when pic-hypertropic strabismus with Fresnel prisms that
the refractive error s optically corrected, a solution superimposed the images for 4 months before the
lies in not correcting the more ametropic eye but patient reported the recovery of sensory fusin. She
in prescribing merely a "balance" lens. Careful gradually regained fusin without the necessity of
evaluation, however, must be conducted before prisms and demonstrated 50 seconds of stereopsis.
the clinician chooses this solution. We have seen This impressive result is not typical, however. If the
several patients adaptwell and experiencefull bin- patient can tolrate superimposition of images, per-
ocular visin and a high degree of stereopsis with haps it is prudent to attempt a functional cure in
as much as 6 diopters (D) of corrected anisometro- such cases. Those who do not readily regain fusin
pia. Some patients having higher degrees of ani- need further management for their intractable
sometropia may show peripheral fusin with diplopia, using principally an occlusion approach.
central suppression with contact lenses or specta- When a patient reports persistent diplopia, and
cles; therefore, they may benefit from full optical single, clear, comfortable binocular visin cannot
correction. be successfully re-established, we usually recom-
In cases of closed head trauma and systemic dis- mend one of three management approaches: some
ease (e.g., diabetes, mltiple sclerosis), some form of occlusion, prism displacement, or hypno-
patients have a bilateral palsy of the superior therapy (Table 15-2).
oblique muscles (a bilateral fourth nerve involve-
ment). von Noorden reported that 21% of fourth
nerve trauma cases are bilateral, but other observ- Occlusion Strategies
ers have found an even higher prevalence.11 This Some patients who experience intractable diplopia
bilateral palsy can result n severe excyclo devia- can tolrate the condition under certain circum-
tion of each eye, particularly at near, which can be stances. They occlude their nondominant eye only
an nsurmountable obstacle to sensory fusin. when critica! viewing s needed (e.g., when driving
Prism compensation is not effective, but patching or reading). Other patients find diplopia intolerable
and visin training may help to advance the heal- at all times and prefer constant occlusion. In these
ing process. These patients can fuse readily in a latter cases, one acceptable solution may be wearing
Chapter15 437
19
nystagmus case (see Chapter 8). If there are signs
TABLE15-3. Management of Congenital of some underlying active pathologic process, refer-
Nystagmus: Therapeutic Options ral and medical treatment are indicated.
For cases of congenital nystagmus n which
there are no indicators of active disease, several
Full correction of the ref ractive error, spectacles or
palliative forms of visin therapy should be tried to
contact lenses Trlal fit wtn rigid gas-permeabte
determine whether (1) control of the nystagmus
contad lenses
can be improved; (2) a cosmetically noticeable
Prisms and added lenses to promote sensory fusin
head turn can be minimized; and (3) increase of
Yoked prisms to treat <15 degrees of abnormal head
binocular visual acuity is possible. Therapeutic
posture
options that are potentially available are Usted in
Standard visin training techniques to increase sen-
sory and motor fusin, if present Table 15-3. These options, other than surgery, can
Afterimage tag techniques to provide visual feed- and should be implemented on a trial basis to see
back of nystagmoid eye movements Mallett's what helps and what does not. The sequence s
technique of ntermittent photopic stimu- flexible and must be varied for each patient. Some-
lation wth the major amblyoscope to increase times, the effect with each option can be dramatic,
motor control and visual acuity long-lasting, and deeply appreciated by the
Auditory biofeedback to build conscious control of patient. However, there are few indicators that pre-
nystagmoid eye movements, at least for short periods dict the outcome. The doctor and patient must
Medications to relieve oscillopsia, if associated explore the possibilities together.
Galilean telescope system to relieve oscillopsia, if
needed
Strabismus surgery, if indicated, to promote sensory Optical Management
and motor fusin, especially in cases of nystagmus In treating binocular anomalies, we have consis-
blockage syndrome tently emphasized the importance of fully correcting
Surgica) procedures (e.g., Kestenbaum operation) to any significant refractive error; in the case of con-
correct large head turns (>15 degrees) genital nystagmus, this principie is even more appli-
cable. Refracting, however, is not easy in nystagmus
cases, for obvious reasons. The prescription needs to
be refined frequently through repetition. Binocular
counsels the patients regarding their emotions sur-
visual acuity may be improved, and nystagmic eye
rounding the condition and sets specific goals for
movements may be lessened, with the wearing of an
hypnotherapy. If such patients are good hypnosis
appropriate spectacle or contact lens correction in
candidates (and not everyone is), they are given a
both afferent and efferent types of nystagmus.
posthypnotic suggestion to ignore the double
In cases of significant refractive error, a trial fit
image and to experience less anxiety about the
with rigid gas-permeable contact lenses should be
problem. Several sessions may be required, but
evaluated and seriously considered as a treatment
some patients benefit greatly from this approach.
option. In some patients, contact lenses have
resulted in immediate improvements of nystagmus
and visual acuity, whereas other patients improve
CONGENITAL NYSTAGMUS over time. Many patients, however, show no
Diagnosis improvement, but this cannot be accurately pre-
Nystagmus, affecting approximately 0.4% of the dicted before a trial fit. The improvements, f they
18
population, is considered to be a "red flag" for a occur, may be attributed to previously undetected
neurologa disorder. Most cases, however, are con- and uncorrected astigmatism that is often associ-
genital, static, and of long duration. The cause of ated with congenital nystagmus. Another possible
congenital afferent nystagmus may be easily identi- explanation is that the lenses cause subtle eyelid
fied (e.g., optic atrophy, ocular albinism, congenital sensations of the nystagmic eye movements; the
cataracts). Determining the etiology can be subtle in patient may learn some degree of nystagmus con-
congenital efferent nystagmus, owing to obscure trol using this form of sensory feedback.
lesions in the brainstem. An effort should be made A prism can be used in some cases of congenital
to determine the cause and characteristics in every nystagmus to diminish the oscillations. One com-
Chapter15 439
congenital nystagmus, photic stimulation does Presently, there are no objective longitudinal
appear to result in some impressive and appreci- reports of the efficacy of biofeedback training for
ated benefits. It seems appropriate to attempt this nystagmus. Some authors have noted that most sub-
technique at some point in the long-term manage- jects after biofeedback training were able to dampen
ment of congenital nystagmus, ideally during the the amplitude and frequency of nystagmus on com-
early school-age years. mand or with conscious intent and to increase fove-
ation time; however, there does not seem to be a
Auditory Biofeedback (T15.5) permanent, complete cure of nystagmus. In a
Several encouraging cases and patient series have detailed study of seven young subjects (ages 7-20
been reported in which auditory biofeedback was years), Mezawa et al.29 reported an average 40%
somewhat successful n the management of con- reduction in nystagmus intensity and an ncrease of
genital nystagmus. Ordinarily, nystagmus patients approximately 190% n the foveation time.
have no sensation, impression, or perception that In general, patients have reported subjective
the eyes are oscillating. Their visual world appears benefits of therapy, including (1) cosmetic lessen-
stable without apparent image movement (oscil- ing of the nystagmus n social situations and n
lopsia), except n a few rare cases. With auditory face-to-face conversations; (2) better visual acuity
biofeedback, the patients' eye position and move- when looking at street signs or watching televisin;
ments are measured using an nfrared eye monitor, and (3) improved psychological adjustment to the
and the signal is converted into an audible tone. presence of nystagmus and satisfaction at gaining
Ratients literally hear their nystagmus. Some sys- some control. The persistence of these perceived
tems provide a continuous tone at which the pitch benefits for 1 year after training has been reported
changes as the eyes oscillate.26-27 Other systems by Ishikawa et al.30 in one-third of their 29 patients.
provide a "dead zone" when the eyes fall on target Another one-third reported modrate long-term
and a signal tone when fixation moves off target.28 mprovement, and the remainder reported poor
Patients attempt to turn the tone off by keeping the results.
eyes steadily on the target. Using this feedback, The potential for applcatin of auditory bio-
affected patients can consciously (and later uncon- feedback techniques in children afflicted with
sciously) learn to alter the motor output to stabilize congenital nystagmus appears to be good. Ciuf-
the eyes. The specific mechanism for accomplish- freda et al.27 reported working with one 4-year-
ing this, however, is not well understood. Mezawa old child and obtaining encouraging results. The
et al.29 found that during voluntary suppression of patient could reduce her nystagmus for brief peri-
nystagmus after training, there was ncreased mus- ods at the initial training session. Clinical bio-
cle tensin in the eyelids and changes in the tonic- feedback systems commercially available are
ity of the laryngeal or pharyngeal muscles. In the anticipated.
embryonic stage, these nerves develop from the
same branchiogenic nerve. These investgateos sug-
gest that biofeedback training possibly makes use Surgical Management
of these common pathways, which may still exist One of the cosmetic consequences in many
after birth.29 cases of congenital nystagmus s a disfiguring
It is surprising how rapidly many patients can learn head posture. The patient naturally prefers a
to lessen the amplitude of their nystagmus. Ciuffreda peripheral field of gaze in which the nystagmus
et al.27 reported five subjects who learned to reduce oscillations lessen and visual acuity improves.
nystagmus amplitude, decrease peak slow-wave Kestenbaum31ntroduced a surgical procedure
velocity, and reduce frequency with less than 1 hour designed to move the nuil point to the primary
of auditory biofeedback training (Figure 15-7). position, obviating the need for a head turn. All
Kirschen28 demonstrated reductions of nystagmus horizontal rectus muscles were operated on to
amplitude in three subjects ranging from 41% to rotate both eyes away from the eccentric nuil
73% within the first hour of training. Frequency, how- point. Resection and recession procedures were
ever, appeared to be less affected by training. Kir- recommended for yoke muscles in each eye,
schen attributed the speedy and large effect on with an dentical amount of adjustment adminis-
amplitude to the specific type of auditory feedback tered to each. For example, to move the nuil
using the dead-zone approach. point from left gaze, resections of the RLR and
442 Chapter15
P 6[ 'f^^^^i^^
LMR are required, along with recessions of the reported this procedure for a patient showing 25
RMR and left lateral rectus (LLR). Several modifi- degrees of chin depression.
cations of the Kestenbaum procedure have been Surgical management of head turns caused by
recommended by various surgeons, and results of nystagmus appears to be promising. In one series
the surgery have improved. The benefits to the of 38 patients, five different modifications of the
patient often are more than cosmetic. There are Kestenbaum procedure were compared.35 In this
objective reports of increased visual acuity with series, the mean age at the time of surgery was 7
the nuil point in the primary position, an overall years (range, 1-35 years), and the average amount
lessening of the nystagmus intensity, and a of head turn was approximately 40 degrees. A
spreading of the nuil point over a wide range of head turn of 15 degrees was considered to be cos-
gaze angles.32'33 For the rare patient having an metically acceptable; using this criterion, an 82%
abnormal vertical head posture, al I four vertical success rate was reported. Overcorrection of more
recti muscles may require surgery. Parks 34 than 15 degrees occurred in only one case. All
Chapter15 443
procedures but one were found to be equally mproves.39 In these cases, the possibility of con-
effective over a follow-up period of approximately vert ng manifest to latent nystagmus by strabismus
3 years. These encouraging results confirm the surgery is a reasonable goal.
results of an earlier clinical series.36
Several recommendations can be made regard-
ng the appropriateness and expectations of surgi-
ACQUIRED NYSTAGMUS
cal ntervention for a head turn secondary to
congenital nystagmus. First, most authorities do Diagnosis
not recommend surgery for a head turn of 15 When a patient presents with acquired nystagmus,
degrees or less.34-37 An attempt is made to manage the presumption s that the cause is a disease pro-
these cases with yoked prisms if there s a small cess of some type affecting oculomotor neurology.
cosmetic head turn. Second, the best surgical A differential diagnosis must be established so that
results have been reported in children aged 4 years the underlying cause can be treated. When the
and older. Many cases of overcorrection have cause is successfully treated, the nystagmus usually
occurred n children younger than 4 years. More- disappears. (SeeTables 8-15 and 8-16 for a descrip-
over, some patients prior to age 4 have spontane- tion of several acquired and, fortunately, rare types
ous remission of their head turn. Third, a surgical of nystagmus.) When the cause s not readily appar-
approach differing from the Kestenbaum proce- ent, computed tomography and magnetic reso-
dure s taken when the nystagmus s complicated nance imaging studies are often indicated. If the
by the presence of a strabismus. In these cases, sur- etiology of nystagmus s attributable to an infec-
gery usually is performed solely on the dominant tious process, a vascular disorder, or a metabolic or
eye to correct for the head turn, because any toxic imbalance, appropriate medications are an
change n head position will be mediated by the indispensable part of the medical management of
fixating eye. the underlying condition. (Description of the many
Treatment of esotropa n nystagmus blockage possible alternatives s beyond the scope of this
syndrome (NBS) during childhood usually requires text.)
an operation after a period of altrnate occlusion
to elimnate amblyopia and to promote ful! motil-
ty of each eye. The Faden operation together with Management
a small recession of the nvolved medial rectus A few medications have been effective in the symp-
may be sufficient, but frequently a bilateral medial tomatic relief of oscillopsia and vrtigo associated
rectus recession s required. The results of surgery with vestibular nystagmus, down-beat nystagmus
generally are not as good as those in cases of con- and, on rare occasions, congenital nystagmus. The
genital esotropa alone. Forexample, von Noorden illusory sensation of movement of an object or the
and Wong38 reported a clinical series of 64 NBS environment s a particularly distressing and debili-
patents whose results were compared to those of a tating symptom. When this symptom occurs, t is
control group of 85 nfantile esotropa cases with- nearly impossible to read comfortably or sustain
out nystagmus. More than one-half of the NBS any demanding visual activity. Symptomatic relief
patients required at least one addtional operation. from an oscillating world, even for a short time, is a
No functional cures were reported in this series; desired goal of all afflicted patients.
however, 26% of the NBS cases ultmately had a Currie and Matsuo40 reported a series of 10
microtropia with some binocular visin. These patients whose vertical oscillopsia associated with
results also suggest a fair cosmetic prognosis down-beat jerk nystagmus was successfully reduced
(approxmately 50%) for children having NBS, or eliminated with the administration of a 1- to 2-
with apparent alignment of the eyes n the primary mg dose of clonazepam. The nystagmus n these
position of gaze. cases had various etiologies: Arnold-Chiari malfor-
In cases of strabismus with nystagmus that mation, cerebellar hemangioblastoma, cerebellar
increases with monocular occlusion (latent com- infarction, and mltiple sclerosis. The nystagmus
ponent), assuming that binocular visin can be and oscillopsia were lessened or eliminated for 2-6
re-established by surgical and optical means, the hours per dose, and one patient experienced relief
nystagmus s frequently converted to merely the for 72 hours per dose. In 7 of the 10 cases, visual
latent form. Binocular visual acuity consequently acuity mproved during the treatment period. The
444 Chapter 15
side effects of this medication are drowsiness and pain when reading. He also was aware of occa-
sedation. These symptoms limit the long-term bene- sional diplopia in secondary and tertiary posi-
fit of the medication in some cases and vary consid- tions of gaze and relied on head turning for
erably between individuis. The primary mode of compensation.
action of clonazepam on the central nervous system Clinical findings were as follows. Refraction and
appears to be through enhancement of the inhibi- acuities were
tory GABAergic system. It primanly reduces the
OD: plano 20/20 (6/6)
slow-phase velocity of the jerk nystagmus. 20/20 (6/6)
O S : +0 . 2 5 -0 .2 5 x 1 0 5
Another drug showing promising results in
reducing oscillopsia and nystagmus amplitude is Type III DRS was
baclofen, which inhibits the excitatory neurotrans- indicated as ductions were restricted n each eye:
mitter system (glutamate). It has been useful in OD, 25 degrees abduction, 15 degrees adduction;
some cases of congenital nystagmus, periodic OS, 50 degrees abduction, 35 degrees adduction.
alternating nystagmus, and seesaw nystagmus.41 Retraction of each eye was observed on adduction.
The reported side effects include drowsiness, dizzi- Cover testing in the primary position of gaze
ness, weakness, hypotension, and nausea. Further- revealed 2A exophoria at far and 10A exophoria at
more, baclofen is expensive. near. The nearpoint of conver-gence was remote
An optical device that is similar to a Galilean (30 cm) but improved to 12 cm with left head turn.
telescope and produces partial retinal image stabi- Relative fusional vergences were fair except for 6A
lization in cases of acquired nystagmus and oscil- BO recovery at near. Vergence facility was poor at
lopsia has been described by Yaniglos and Leigh.42 far and near. Accommodative amplitudes and
This device consists of a high-plus spectacle lens facility were normal monocularly but marginally
used in combination with a high-minus, rigid, gas- adequate with binocular viewing. Negative and
permeable contact lens. A patient with mltiple positive relative accommodation were normal.
sclerosis achieved 30-90 minutes of relief from Fixation in the primary position was normal
oscillopsia and improved visual acuity by wearing monocularly and binocularly. OD pursuits were
a monocular spectacle-contact lens combination, slightly jerky and restricted with narrowing of the
+17 D and -28 D, respectively. The device has lim- palpebral fissure on adduction, whereas OS pursuits
ited depth of field and cannot be tolerated for long were smooth but restricted on adduction with nar-
periods due to discomfort, but patients appreciate rowing of the palpebral fissure. OD saccades were
the periods of stabilized imagery for specific activ- restricted, with narrowing of the palpebral fissure on
ities, such as watching televisin. adduction, whereas OS saccades were normal but
Some cases of persistent acquired nystagmus and slightly restricted on adduction, with narrowing of
debilitating oscillopsia that have not responded to the palpebral fissure; binocular testing revealed sig-
conservative therapy have benefited by retrobulbar nificant restrictions (Figure 15-8). Binocular fusin
injections of botulinum toxin. In one series of 12 testing, using a tangent screen at 1 m with a pen-
patients, 8 demonstrated an increase in visual acu- light target to plot the rea of fusin, revealed a hor-
ity.43 Injections were repeated at 3- to 4-month izontal extent of 4 degrees on left gaze and 8
intervals as long as patients noted an improvement degrees on right gaze for a total of 12 degrees of
in their quality of Ufe. bifixation without head turning.
Because of complaints with reading, the King-
Devick test (see Chapter 2) was given, and reading
CASE EXAMPLES saccades were found to be normal. Also, the Dys-
lexia Screener45 was administered; the patient
Case 1: Duane scored above normal on phonetic and eidetic
Retraction Syndrome coding, thus ruling out dyslexia as a cause of read-
Griffin and Carlson44 reported successful results ing problems.
with visin therapy n a 10-year-old boy with The patient was comanaged with his pediatric
Duane retraction syndrome (DRS) (see Chapter ophthalmologist. The agreement was that there
8). DRS of this patient was first diagnosed at age was no strabismus in the primary position of gaze
3 by a pediatric ophthalmologist. On presenta- and that there was a slightly abnormal head pos-
tion, the patient reported discomfort, fatigue, and ture (of no great concern to the patient). The oph-
thalmologist thought that forced duction testing
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 na rrowing of the right palpe-
bral fissure that s made more obvious by the right hypertropia n this position of gaze.
need not be repeated. Also, extraocular muscle these binocular anomalies. The management plan
surgery was not a feasible option. The principal n visin therapy entailed two major approaches.
problem was that of gross convergence insuffi- First, no spectacle lenses were necessary, but
ciency; a secondary problem was poor binocular yoked prisms could be tried to elimnate the head
accommodative facility. The symptoms associated turn. These were applied for 30 minutes n the
with prolonged reading were probably due to office but with no beneficial effect. Second, visin
446 Chapter15
training was prescribed to improve positive ing. These symptoms had been noticed for many
fusional vergence, gross convergence, and accom- years. His lens prescription and acuities were as
modative facility. Vision training in such cases for follows:
improving the restricted motility is usually ineffec- 20/15 (6/4.5)
OD : -3 .5 0 - 0 .7 5 x 1 4 0
tive, although fusional vergence training can be 20/15 (6/4.5)
OS: -3.75 -0.75 x 020
attempted.5 Vision training was performed only at
home using Minivectograms and pencil push-ups Altrnate cover testing showed a small exopho-
in all positions of gaze. ria, approximately 10A at far and near, with a hyper
After a 2-month period of home visin training, deviation of the left eye on continuous testing. A
most of the restrictions of DRS remained; however, base-down prism before the left eye was gradually
the patient's BO recovery at near had improved introduced in increasing amounts as the vertical
from 6A to 14A, and binocular accommodative facil- deviation increased, ultimately stopping with 50 A
ity had improved to 6 cycles per minute. Recovery base-down.
speed was noticeably improved in all Bl and BO The left eye was patched, and the patient was
testing. Also, the patient's speed on the King-Devick allowed to rest for 30 minutes. When the patch
test improved from 77 to 59 seconds. These was removed, the left hyper deviation was 26A. As
improvements may have been responsible for the greater power of the base-down prism was given
patient's report that comfort and efficiency of visual while the patient maintained fusin, the deviation
tasks at near, particularly when reading, had stabilized with 52A base-down after 10 minutes,
improved. The patient was advised to continu the presumably through prism adaptation (Figure 15-9a).
home visin training and return n 1 year. Follow-up When the vertical prism was removed, the patient
history indicated that the patient is doing well quickly regained fusin; this was objectively
except for occasional fatigue during reading and s a observable, and the patient reported the merging
good pitcher, although not a good batter, in base- of the momentarily seen diplopic images (see
ball. The patient and parents expressed gratitude Figure 15-9b). Other testing indicated that the right
that visin therapy was administered and significant eye was the dominant eye and that there was inter-
improvement of binocular status was achieved. mittent central suppression of the left eye. The
Hess-Lancaster test suggested a mild paresis of the
left inferior rectus and, possibly, of the right infe-
Case 2: Noncomitant rior oblique muscle. It can be speculated, how-
Intermittent Hypertropia ever, that left superior oblique muscle paresis
Bergin et al.46 reported a case of hyperphoria of occurred early in the patient's life and that there
large magnitude with mild noncomitancy. The was an eventual spread of comitancy. Pursuit
patient was a 27-year-old man who presented with movements were normal, but the patient showed
no symptoms other than noticing momentary frequent regressions on reading tasks. Nearpoint of
diplopia when tired and having a dislike for read- convergence was normal. Stereoacuity was 30 sec-
ing, especially when fatigued with prolonged read- onds of are, and Bl and BO motor fusin ranges
Chapter15 447
were fair but slightly limited. Fixation disparity tagmus on attempted up-gaze. She could fuse in
testing revealed a left hyper fixation disparity with down-gaze and left gaze and therefore adopted an
neutral ization varying from 5A to 20A. elevated head (chin) position of 30 degrees and a
To summarize briefly, a visin training program head turn 10 degrees to the right. The patient was
was designed to ncrease Bl and BO fusin ranges wearing bifocal spectacles without any prism that
over a period of several weeks, mostly at home. gave her adequate visual acuity and fusin for
They were sufficiently ncreased to provide the reading in down-gaze.
patient with more comfort with reading tasks. The initial therapeutic approach was to pre-
Because the patient was a college student, this was scribe yoked vertical prisms (base-up) in an
greatly appreciated. There was little vertical ver- attempt to reduce the chin elevation and the left
gence training; expanding horizontal vergences hypertropia. The single visin prescription (for dis-
was emphasized. The vergence techniques for tant visin) that optimally accomplished these
home training included the use of Vectograms, goals and provided acceptable visual acuity was
Aperture-RuleTrainer, Brock string and beads, and
OD: +0.75 DS -1.00 DC x 023 with 15 A base-up
chiastopic fusin cards. The major amblyoscope
20/20-OS: -1.75 DS -1.50 DC x 168 with 8A
was also used in a few office training sessions.
base-up 207
Because of the absence of past pointing and an
20-
unremarkable case history, no other treatment was
recommended. Prism compensation was not rec- After wearing this correction for 2 weeks, the
ommended because of the prism adaptation that patient presented with only 10 degrees of chin ele-
occurred in this case. Extraocular muscle surgery vation and had binocular fusin for far viewing.
was neither recommended or elected by the This amount of elevation was acceptable to the
patient as a viable treatment option. The patient patient and was not cosmtica!ly noticeable. Hav-
always had fusin under ordinary seeing condi- ing learned to turn her head more than her eyes,
tions, and fusional vergences had been normalized she experienced fusin most of the day with these
with visin training. The results were successful, spectacles. A second pair of spectacles for reading
and visin training appeared to be the best choice without incorporating a prism was prescribed,
of treatment for this patient. An mportant point is because at approximately 30 degrees n down-
that vertical deviations can sometimes be managed gaze, she showed no vertical deviation and only a
successfully by improving horizontal deviations. small exophoria. The single visin reading pre-
Another important point exemplified by this case s scription was
that latent deviations must be brought out with
OD:+3.25 DS-1.00 x 023
time; the clinician should conduct a prolonged
OS:+0.75 DS-1.50x168
occlusion test to reveal the full deviation that may
be responsible for a patient's symptoms. This reading prescription gave her good visin and
binocular fusin for most nearpoint activities, but
she also noticed that she could move her eyes only
Case 3: Acquired approximately 15 degrees before she saw an inter-
Third Nerve Palsy mittent diplopic image. There was significant hori-
A 53-year-old woman reported constant vertical zontal noncomitancy of the deviation, leaving her
diplopia n the primary position and the necessity fusin field restricted.
of using extreme chin elevation to achieve binocu- The patient was given two visin training tech-
lar fusin. Two years previously, she had experi- niques with goals of strengthening her horizontal
enced a basilar artery aneurysm resulting in a fusional vergence ranges (which were deficient) and
bilateral third nerve paresis, left facial palsy, and expanding her field of binocular fusin. She did Bl
balance problems. Neurovascular surgery at the and BO sliding vergence training for approximately
time saved her life. With healing, she regained 20 minutes per day using either a Minitranaglyph
some of the lost functions; her balance improved (see Figure 16-6) or Minivectogram that has a stere-
as did the facial palsy, but she presented with a sta- opsis target for fusional lock. Also, several times
ble bilateral restriction of up-gaze (-3), a constant, daily for approximately 5 minutes, she attempted to
noncomitant, unilateral, left 11 A hypertropia expand her field of fusin n all directions, particu-
decreasing in down-gaze, and horizontal jerk nys- larly horizontal. She would attempt to maintain a
448 Chapter15
stereo fusin lock on the Minivectogram as she Fusiona! evaluation on the major amblyoscope indi-
slowly moved it into secondary and tertiary fields of cated second-degree fusin at the subjective angle
gaze (T15.1). After 2 months of training, she had but very limited fusional vergence ranges in Bl and
doubled her near vergence ranges to Bl A/21/13 and BO directions, due primarily to the variable hyper
BO A/24/14. The horizontal fusin field had and cyclo deviation.
increased to 35 degrees. Prism compensation was attempted at both far
Although there was no improvement with the and near without success; superimposition of the
superior gaze palsy, the patient felt gratified with images was possible, but sensory fusin did not
the results of the prism spectacles and visin train- occur or was unstable. Vision training was consid-
ing and was released from therapy. She was asked ered as a treatment option but was rejected due to
to continu these training techniques on a periodic the noncomitant cyclo nature of the deviation and
basis indefinitely, once per week, to prevent the impracticability of an in-office-based training
regression, and was placed on a yearly recall for program in this case. Vertical and horizontal prism
primary care visin examinations. On a progress displacement was tried to determine whether sup-
visit 6 years later, this patient's condition was sta- pression would be easier for the patient; it was not.
ble, and her horizontal fusin field had increased The patient's main problem was visual confu-
to 45 degrees even though she had not continued sin. Because the patient had good visual acuity in
her retainer exercises. each eye, a monovision spectacle correction was
evaluated using a trial frame. The patient's farpoint
Case 4: Intractable Diplopia correction was placed before the right eye and the
nearpoint correction before the left, as that eye was
A 67-year-old woman presented with a 4-year his-
hypotropic already in down-gaze. The patient's ini-
tory of Graves' disease (thyroid ophthalmopathy).
tial response was the report of diplopia, but now
This patient reported constant diplopia and visual
there was one clear and one blurred image. With a
confusin (overlapping images) atfar and near dur-
little practice, the patient was able to altrnate fixa-
ing this period; she wore a patch over her left eye
tion easily between far and near. The following pre-
for driving. The hyperthyroid condition was being
scription was given for a trial period of wear:
medically managed and was reported to be stable.
By gross inspection, her eyes appeared slightly OD: -1.25 -0.50 x 095 20/20 (at 6 m)
proptotic, the left more than the right; the slight OS: +1.00 -0.25 x 088 .4M (at 40 cm)
eyelid retraction revealed a small portion of sclera
The patient was instructed to wear the monovi-
superiorly (Dalrymple's sign), but the corneas were
sion correction for as much time as she could dur-
not constantly exposed. She was not concerned
ing a trial period of 2 weeks. At the progress check,
about cosmesis, only about the diplopia.
she reported that the monovision correction seemed
Refraction and acuities were as follows:
to be a major improvement. She had learned to
OD: -1.50 -0.25 axis 095 20/20 +2.50 add .4 M ignore the blurred image even during critical view-
(20/20 at 40 cm*) OS: -1.25 -0.50 axis 088 ing, such as televisin and reading. Diplopia was
20/20 +2.50 add .4 M noted less frequently as she gained experience with
(20/20 at 40 cm*) monovision spectacles. At a 6-month progress
Ocular motility and binocular visin assessment check, the deviation had not changed significantly,
revealed a noncomitant, constant, unilateral, left 7A but she was essentially symptom-free, except for
hypotropia and 3A exotropia at far and a constant high-contrast situations, such as viewing streetlights
left 3A hypotropia and 12A exotropia at near; subjec- at night.
tive testing with the double Maddox rod technique
indicated a left 6-degree excyclo deviation that
Case 5: Congenital Nystagmus
changed with the field of gaze. Motility was
restricted in up-gaze: -2 OD, -3 OS, presumably A 13-month-old male child was brought in by his
due to contracture of the inferior rectus muscles. parents for his first complete eye examination. His
parents had the following questions: Why did the
child have nystagmus? How well did he see? What
*Multiply the M number by 50 for reduced Snellen equivalen! could be done for him? The mother had a normal
(e.g., 0.4 x 50 = 20). prenatal history and a relatively easy delivery (onlv
Chapter15 449
9. Marain'mg SM. Anomalous retinal correspondence and 30. Ishikawa S, Tanakadate A, Nabatame K, Ishii M. Biofeed
monolateral squint. Ophthalmologca. 1967;153:179-183. back treatment of congenital nystagmus. Neum-Ophthal-
10. Revell MJ. Anomalous retinal correspondence: a refrac- mology. 1985;2:58-65.
tive treatment. Ophthalmic Optician. 1971 ;2:110-112. 31. Kestenbaum A. Nouvelle operation de nystagmus. Bul!
11. von Noorden GK. Binocular Vision and Ocular Motilty, Soc Ophtalmol Fr. 1953;6:599.
6th ed. St. Louis: Mosby; 2002:438. 32. Dell'Osso LF, Flynn JT. Congenital nystagmus surgery: a
12. London R, Scott SH. Sensory fusin disruption syndrome. quantitative evaluation of the effects. Arch Ophthalmol.
JAm OptomAssoc. 1987;58:544-546. 1979;97:462^69.
13. Worth C. Squint: Its Causes, Pathology, and Treatment. 33. Flynn JT, Dell'Osso LF. The effects of congenital nystag
PV\\\adeVph\a-. BVakvston's; A 921. mus surgery. Ophthalmology. 1979;86:1414-1427.
14. Pratt-)ohnson )A, T\\\son G. Kcqu'wed cen\ra\ d\stupor\ oi 3>A. VatVs RVA. Cor\gs[\\\a\ wysXagmus svvtgary. Am Orthopt J.
fusional amplitude. Ophthalmology. 1979;86:2140-2142. 1973;23:35-39.
15. Burger DS, London R. Soft opaque contact lenses n binocu 35. Mitchell PR, Wheeler MB, Parks MM. Kestenbaum surgical
lar visin problems. J Am Optom Assoc. 1993;64:176-180. procedure for torticollis secondary to congenital nystag
16. London R. Monovision correction for diplopia. J Am mus. J Pediatr Ophthalmol Strabismus. 1987;24:87-93.
OptomAssoc. 1987;58:568-570. 36. Scott WE, Kraft SP. Surgical treatment of compensatory
17. Kirschen D, Flom MC. Monocular central-field occlusion head position in congenital nystagmus. J Pediatr Ophthal
for ntractable diplopia. Am ] Optom Physiol Opt. 1977; mol Strabismus. 1984;21:85-95.
54:325-331. 37. Nelson LB, Wagner RS, Harley RD. Congenital nystagmus
18. Anderson JR. Latent nystagmus and alternating hyperpho- surgery. Int Ophthalmol Clin. 1985;25:133-138.
ria. BrJ Ophthalmol. 1954;38:217-231. 38. von Noorden GK, Wong SY. Surgical results n nystagmus
19. Crisham D. Management of nystagmus n young children. blockage syndrome. Ophthalmology. 1986;93:1028-1031.
Probl Optom. 1990;2:496-527. 39. Zubcov AA, Reinecke RD, Gottlob I, et al. Treatment of man-
20. Dickinson CM. The elucidation and use of the effect of ifest latent nystagmus. Am J Ophthalmol. 1990;110:160-
near fixation in congenital nystagmus. Ophthalmic Phys 167.
iol Opt. 1986;6:303-311. 40. Currie JN, Matsuo V. The use of clonazepam n the treat
21. Metzger EL. Correction of congenital nystagmus. Am J ment of nystagmus-induced oscillopsia. Ophthalmology.
Ophthalmol. 1950;33:1796-1797 1986;93:924-932.
22. Healy E. Nystagmus treatment by orthoptics. Am Orthopt 41. Yee RD, Baloh RW, Honrubia V. Effect of Baclofen on
i. 1952;2:53-55. Congenital Nystagmus. In: Functional Basis of Ocular
Motility Disorders. Lennerstrad G, Zee DS, Keller EL, eds.
23. Stegall FW. Orthoptic aspects of nystagmus. Symposium
Oxford, U.K.: Pergamon; 1982:151-157.
on nystagmus. Am Orthoptic]. 1973;23:30-34.
42. Yaniglos SS, Leigh RJ. Refinement of an optical device
24. Mallett RFJ. The treatment of congenital idiopathic nys
that stabilizes visin in patients with nystagmus. Optom
tagmus by intermittent photic stimulation. Ophthalmic
Vis Sci. 1992;69:447-450.
Physiol Opt. 1983;3:341-356.
43. Rubn ST, Lee JP, O'Neil D, et al. The use of botulinum
25. Brinker WR, Katz SL. A new and practical treatment of
toxin for treatment of acquired nystagmus and oscillop
eccentric fixation. Am J Ophthalmol. 1963;55:1033-1035.
sia. Ophthalmology. 1994;101:783-787.
26. Abadi RV, Carden D, Simpson J. A new treatment for con 44. Griffin JR, Carlson GP. Duane retraction syndrome and
genital nystagmus. BrJ Ophthalmol. 1980;64:2-6. visin therapy: a case report. J Am Optom Assoc. 1991;
27. Ciuffreda KJ, Goldrich SG, Neary C. Use of eye move- 62:318-321.
ment auditory biofeedback n the control of nystagmus. 45. Griffin JR, Walton HN, Christenson GN. The Dyslexia
AmJ Optom Physiol Opt. 1982;59:396^t09. Screener (TOS). Culver City, Calif.: Reading and Percep-
28. Kirschen DG. Auditory feedback in the control of congenital tion Therapy Center; 1988.
nystagmus. Am) Optom Physiol Opt. 1983;60:364-368. 46. Bergin D, Griffin J, Levin M. Hyperphoria of large magni-
29. Mezawa M, Ishikawa S, Ukai K. Changes in waveform of tude: a case report. Am J Optom Arch Am Acad Optom.
congenital nystagmus associated with biofeedback treat 1972;49:947-950.
ment. BrI Ophthalmol. 1990;74:472-474.
Chapter 16 / Therapy for Vision Eff iciency
When the amount of needed magnification has (e.g., +3.00), C = thickness of lens (in meters) divided
been estimated, a doctor can prescribe seikonic by the ndex of refraction (e.g., 0.002/1.53), and ^ =
lenses by manipulating the lens parameters of the front surface power in diopters (e.g., +9.00).
least magnified eye through trial and error, if nec- Using this formula and calculating with the num-
essary, to increase its magnification to compnsate bers in the example, M = 1.05, or 5% magnification
for the patient's aniseikonia. A rough clinical for one eye (e.g., right eye). If a lens for the left eye
guideline for lens design is to equalize the base has the following specificationsFv= +5.00, C -
curve and thickness of the least-powered lens to 0.003/1.53 (Le., thicker lens), and F, = +11.00then
that of the greater. The foregoing techiques of
actually measuring a patient's image size differ- M =1
ence and then compensating for that difference [1 -.013(5)]A[1 -.003/1.530(11)]
with optics provides a level of control needed to = 1.09, or 9% spectacle magnification
help many symptomatic aniseikonic patients.
A certain percentage of undercorrection (e.g., Predicted aniseikonia is calculated as left-eye M -
0.5%) is acceptable due to presumed patient toler- right-eye M, or 9% - 5% = 4%.
ance. Spectacle magnification can be accom- If the thickness of the lens of the right eye were
plished by appropriate modification of the shape 5 mm and the front surface power were increased
factor of an ophthalmic lens (which depends on to +11.00 D, then M would be calculated as 1.08,
the front base curve and thickness of the lens) or or 8% spectacle magnification. Predicted aniseiko-
the power factor (which depends on the vrtex nia would then be left-eye M - right-eye M, or 9%
power and vrtex distance of the lens). Because - 8% = 1%. This 1% difference of ocular image
the power factor can be modified only slightly size would be more tolerable to an affected patient
without undercorrecting or overcorrecting the than would the 4% difference. Note that this
ametropia, the shape factor is the variable that is example applies to overall aniseikonia. Meridional
most often considered to crate the desired magni- aniseikonia would require direct comparison and
fication. Kleinstein 9 gave the magnification for- calculations of various meridians for toric iseikonic
mula for the shape factor as follows: prescription lenses.
M= 1,] In summary, aniseikonia is a binocular anomaly
[ 1 - Z1F v l A M - C F
and should be considered; testing should be con-
where M = ducted in the setting of unexplained symptoms.
magnification, Z = vrtex distance in meters Some patients may need iseikonic correction to
(e.g., 0.013), Fv = vrtex power n diopters achieve comfortable and efficient binocular visin.
Chapter16 455
We recommend direct measurement of image size On the basis of our experience, we do not rec-
difference between the eyes and manipulation of ommend the monovision approach to patients
the shape factor in ophthalmic lens design to whose binocular status is frage or poor. Lebow
reduce aniseikonia to within tolerable limits. and Goldberg16 reported that 20% of their mono-
vision patients were unable to achieve second-
degree fusin. For example, we consider intermittent
exotropes to be poor candidates for a monovision
MONOVISION
prescription. If such patients insist on wearing
Some presbyopic patients, particularly successful monovision contact lenses, the doctor should, in
contact lens wearers, prefer a monovision contact response, recommend visin training to improve
lens prescription rather than the traditional solu- fusional skills. This training could possibly coun-
tion of spectacle bifocals. Because these patients teract the adverse effects of monovision contact
usually have normal binocular visin, they choose lens wear. Conversely, we do use a monovision
to disrupt their binocularity by wearing a contact approach in some cases of binocular anomalies
lens correcting the farpoint ametropia on the dom- (e.g., amblyopic patients who are managed with
nant eye and a contact lens add for nearpoint optical penalizaron; see Chapter 10) and in some
viewing on the nondominant eye. The primary cases of intractable diplopia.
advantage of monovision contact lenses is self-
evident: There is no need for spectacles. In addi-
tion, monovision can provide far and near visin SACCADIC EYE MOVEMENTS
independent of field of gaze. Unlike bifocals,
Some patients have deficient control of their saccadic
monovision contact lenses do not often present
eye movements and may benefit from visin training.
visin problems while affected individuis are
Amblyopic patients are the most common example
descending or ascending stairs. However, monovi-
of this, but some unilateral strabismic patients who
sion is accurately described as optically induced
are nonamblyopic have poor saccadic skills with the
anisometropia. When a monovision patient is care-
deviating eye. Some school-aged children with read-
fully tested, foveal suppression will often be found.
ing disabilities also have fine and gross motor imma-
In monovision patients, stereopsis measures on
turity that may be reflected in their control of
average 60-90 seconds of are.10'11 This represents a
saccadic eye movements. Other children, indepen-
small reduction, but monovision contact lens
dent of a learning disability, have poor saccades and
wear does affect accuracy in some occupational
eye-hand coordination that may limit sports perfor-
tasks.12 Monovision also compromises visual reso-
mance and cause inefficiency in other activities in
lution under low-contrast viewing conditions,
school, work, and play. Al I these patients may benefit
especially for adds of more than 1.50 D. 13 This
by participating in a visin therapy program,
means that contrast sensitivity for night driving, for
although it is often not clear what part maturation
example, can be significantly reduced.
plays in the outcome. Nevertheless, testing of sac-
Whether monovision contact lens wear is in a
cades (see Chapter 2) should be administered when
patient's best interest is a decisin that must be
children have behavioral and performance problems
carefully made by the patient in consultation with
in school; visin therapy should be considered.
the doctor. What must be seriously considered is
the patient's need for binocular visin efficiency
and the chances of producing symptoms. We gen- General Approaches to Training
erally do not recommend monovision contact It is best to begin with monocular saccadic training
lenses to presbyopic patients who have high visin of the right eye or left eye alone. After each eye is
requirements (e.g., commercial drivers, pilots, sur- shown to perform equally well, the program may
geons, lawyers, or computer operators). These proceed to binocular training. Table 16-3 lists gen-
patients often are not successful in making the eral approaches to training for saccadic eye move-
adaptation. Drivers can experience an annoying ment dysfunction.
glare at night14; depth perception and resolution
can be reduced for critical nearpoint work 12; and Stepl
degraded binocularity can result in asthenopia The first step in visin training for good saccadic
with prolonged reading demands.15 eye movements is to ensure good fixation ability of
456 Chapter16
T16.1 Fixatng and picklng up objectson a tabletop{e.g., toys, raisins, peanuts, cookie sprinkles, Iridian
beads). All 10 principies apply.
T16.2 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 tactile-
kinesthetic support. The goals are accuracy and speed of eye-hand coordinaton.
TI 6.3 Peg-board type games (e.g,, Lite-Brite, geoboards). The patient s instructed to place the pegs in the appro-
priate holes as quickly and accurately as possible. (See Figure 16-3, which depicts a Lite-Brite game.)
T16.4 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.
T1 S.5 Fixations with an aftermage, This provides good feedback as to accuracy of eye movements and fixa-
tions and can be applied to most other specific training technques.
T16.6 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 19-
3cinPartThree).
T16.7 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.
T16.8 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).
T16.9 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.
T16.10 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.
T16.11 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.
T16.12 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 pro-
grams all have tasks dedicated to building ocular motilty.
efficient and accurate for saccades than are the patients to balance an object (e.g., small wooden
relatively gross neck and body muscles. Most block) on the head.
patients (even those with neurologic soft signs)
can voluntarily learn to control their head move- StepS
ments when making saccadic eye movements. Auditory stimuli can be introduced into the sac-
Reading efficiency may mprove as a result. Head cadic visual task to ensure that affected patients are
movements are normal ly made, however, for able to sequence n a left-to-right fashion, as in writ-
large saccadic eye movements beyond 15 ten English. Patients should be able to develop the
degrees.17 An effective means of reducing head ability to keep up with the rhythm of a metronome.
movements during saccadic training s to require To proceed from less difficult to more difficult,
458 Chapter16
Step9
The development of automated, reflexive saccades
is involved in step 9. Patients should be able to cope
with cognitive demands (commensurate with men-
tal 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 perfor-
mance, 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
><
FIGURE 16-2Saccadic Fixator. (Courtesy of Wayne Engineering.)
responses so that visin therapy is successful. More-
over, 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.
made in such cases, in which saccades were very the patient's eyes. In step 4, the goal is to ensure
inaccurate at the beginning of therapy but improved good eye-hand coordination. The patient picks up
accuracy was achieved afterward. If speed can be each peanut in turn as accurately and quickiy as
increased, good left-to-right sequencing developed, possible. The patient's reward can be eating the pea-
motor planning with rhythm achieved, and unnec- nuts. Step 5 provides for each eye to be trained until
essary head movements eliminated, patients are there is equal ability. In step 6, the patient views the
better off than before visin therapy, even if the full peanuts with both eyes, repeating steps 1-4. An
goals of speed and accuracy are not attained. afterimage tag gives important visual feedback to the
patient and can be used at each step in this
sequence. In step 7, the patient is nstructed to elim-
Specific Techniques nate head movements (with an object balanced on
(T16.1-T16.12) the head) when looking at and picking up the pea-
Many types of fixation targets can be used for sac- nuts. For the eighth step, hand clapping or a metro-
cadic training techniques. The 12 exemplary tech- nome can be used as the patient picks up peanuts in
niques usted in Table 16-4 can be applied to the rhythm to the auditory stimulus. In step 9, the patient
general training approaches just described (and attempts to pick up the peanuts while simulta-
fcted in Table 16-3). Using ordinary objects as in neously trying to answer questions asked by the ther-
TI 6.1, the first step is for the patient to fixate the apist. This is a cognitive loading method. Finally, in
i object (e.g., a peanut) steadily for several seconds. step 10, the therapist provides feedback to the
| The therapist observes the patient's eye and provides patient as to any remaining inaccuracies in saccadic
i feedback, regardless of whether there is steady fixa- eye movements. The specific training techniques
I Son. The use of an afterimage for the patient's sub- (T16.2-T16.12) should be applied to the general
Ijective feedback as to accuracy of fixation can also training approaches usted in Table 16-3. Not every
| le used. In step 2, peanuts can be widely dispersed training device may apply to every general
a tabletop for gross saccadic training; with approach. Sophisticated instruments (e.g., computer-
roved performance, the peanuts can be placed ized programs) are available for special uses to mot-
closely together for fine saccadic training. In 3, the vate patients, but techniques using simple objects
patient is encouraged to look from one iut to the usually suffice for effective in-office and home visin
next as quickiy as possible. The perfor-ce can be training to improve saccadic eye movements (refer
timed as the therapist closely watches to Figures 16-4 and 16-5 for examples).
460 Chapter16
PURSUIT EYE MOVEMENTS General particular pursuit task. Initially, the tracking
responses may be a combination of pursuit and sac-
Approaches to Training cadic eye movements. Even persons with good pur-
Many clinicians recognize a cise relation between suits will break down and begin using saccades as
poor pursuits and poor performance in school, work, the velocity of the target is greatly increased (to
and athletics. Yet, there is little research to verify pos- more than 30 degrees per second). Affected patients
itive resulte from therapy. We believe, however, that attempt to coordnate saccadic and pursuit move-
it is beneficial to have smooth and accurate pursuit ments to maintain fixation on the moving target.
eye movements. If pursuits are deficient or imma- Such patients are encouraged to use all the volition
ture, visin training can often improve tracking skills.
Pursuit training is particularly useful to increase
excursions when there is restricted motility in cases TABLE 16-5. General Approaches to Improvement of
of noncomitancy.This is also mportant in amblyopia Pursuit Eye Movements
therapy to promote foveal fixation. iThe following
therapeutic approaches are sequenced from easy to
1. Steady position maintenance of stationary target
more difficult.18 General approaches to improve pur-
suit eye movements are Usted in Table 16-5. 2. Voluntary to reflexive responses
3. Eye-hand coordination to no eye-hand support
Sfep 4. Small to large excursions
The goal in step 1 is to ensure that affected patients 5. Slow to fast speed of pursuits
have adequate position maintenance of a station- 6. Jerky to smooth movements
ary target. Establishing central steady fixation of 7. Head movement to no head movement
each eye is a prerequisite to effective pursuit train- 8. Inequality to equality of right eye and left eye
ing and should be the primary step in evaluating
9. Monocular to binocular pursuits
any of the eye movement systems.
10. Simple to complex cognitive demands
Step 2 11. Sitting to standing position
Step 2 involves proceeding from voluntary to reflex- 12. No vergence demand to prismatic demands
ive responses. The concept of mental effort is useful. 13. Combinations of less stress to more stress
Patients' attention must be actively engaged in the
Chapter16 461
T16.13 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 excur-
sions can be increased by having the patient move closer to the target.
T16.T4 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,
T16.15 Penlight pursuits (office or home). fn the office, the therapist moves the penHght target in various direc-
tions while the patient attempts to follow t smoothly and accurately. At home, the helper (e,g., par-
ent, sibling, friend) acts as a therapist to provide the target movements.
T16.16 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 coun-
terclockwise direction.
T16.17 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 ther-
apist'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.
T16,18 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 base-
out demands are presented. The target can be moved into various felds of gaze for pursuit training
while sensorimotor fusin is monitored and trained.
T16.19 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.
Clinicians, however, may wish to vary this sequence, s similar to the testing procedure described in
depending on the particular needs of their patients. Chapter 2. Note that 2.00 D s the standard power
for testing young patients, but training beyond that
Step 1 criterion is recommended. (With older, but nonpres-
The goal of step 1 s to increase the patient's byopic, adults, less power may be appropriate, such
monocular accommodative amplitude to its mxi- as 1.50-D flippers.) This lens rock training assumes
mum. Our preferred techniques include accom-
modative push-ups (T16.21) and jump focus
exercises (T16.22). This step s omitted f patients
initially have sufficient amplitude. Also, presby- TABLE 16-7.
Approaches to Accommodative
Training
opic patients and those having organic lesions lim-
iting accommodation are excluded from this type
of therapy. Speed is not an important consideraron 1. Achieve sufficient accommodative
amplitude
in this step, but amplitude and accuracy of focus
monocularly.
are. A training goal should be an accommodative
2. Monocularly, achieve a range of 2.50 D untimed;
amplitude commensurate with the mean for an
proceed from small to large ranges
affected patient's age (see Chapter 2).
3. Achieve 20 c/min monocularly; proceed from slow
to fast.
Step 2
4. Stimulatory and inhibitory phases should be quick.
Accommodative facility and stamina are mproved 5. Facility of the right eye and left eye should be equal.
n step 2 by changing the accommodative stimulus 6. Introduce bi-ocular rock.
demand, beginning with small steps and proceeding 7. Introduce binocular rock, achieving goals in steps 1-4.
to large. For example, using monocular accommo- 8. Introduce base-in and base-out prism demands dur-
dative flippers, training proceeds from small to large ing binocular rock.
lens powers (e.g., from 0.50 to +2.50 D). Training
464 Chapter16
that patients have the fu 11 refractiva correction (cor- with a prism (e.g., 10A base-down). This should cr-
rected ametropia most plus [CAMP] lenses) n place, ate vertical diplopia. A single line of Snellen letters
particularly myopic patients. The target should be can be used (e.g., 20/30 acuity demand). If the
detailed nearpoint print. Patients alternately clear base-down prism is placed before the left eye and
the print as quickly as possible with each flip of the that eye views through a minus lens, the image will
lenses. Training progress can be recorded in two dif- be higher and will be an accommodative stimulus.
ferent ways. The time can be recorded for a given The right eye views the lower image through a plus
number of lens flips (or cycles) or, conversely, the lens, which requires inhibition of accommodation
number of flips (cycles) can be noted vvithin a cer- for clarity. Patients alternately fixate the targets with
tain time limit. Out-of-office flipper training can be increasing speed. The power of the lenses can be
accomplished conveniently because very little increased as training progresses.
equipment is necessary.
Step 7
Step 3 Binocular accommodative rock is introduced n
Speed rather than amplitude is emphasized in step step 7. Training s similar to testing procedures (see
3. The ideal goal is to have patients achieve 20 Chapter 2). The same goals of range and speed in
cycles per minute on accommodative rock. Using the first six steps also apply to binocular rock.
accommodative flippers (T16.23), for example, Training can be near-far-near jumps and lens rock
once adequate speed s achieved with low-power with flippers. The ideal goal is 20 cycles per
lenses, higher powers are used until the ideal minute using 2.50-D flippers.
range of clear visin (if possible for a particular
patient) of 2.50 D is achieved with a speed of 20 Step 8
cycles per minute. Introduce Bl or BO demands while the patient s
performing binocular accommodative rock. Fresnel
Step 4 prisms are good for this purpose.
The stimulatory and inhibitory phases of jump
focus (near-far-near rock) or accommodative flip- Optical Management Plus-
per (lens rock) training should be equalized. Lens Additions
Patients having trouble in clearing the target Plus-addition lenses are usually associated with
through plus lenses in flipper training, for example, the correction of presbyopia, and they are some-
should work on this problem both n the office and times prescribed for children and young adults,
at home. When equality s achieved for plus and although not without controversy.19"21 We have
minus lenses, patients move on to the next step. seen certain young patients with accommodative
problems improve in reading and other nearpoint
StepS tasks when wearing plus-lens additions (either sin-
The accommodative skills of each eye should be gle visin reading lenses or bifocals). Plus-lens
approximately equal. Sometimes achieving this additions may be considered when there is a large
goal s not possible for many reasons (e.g., ocular accommodative lag and if there s accommodative
pathology or incurable amblyopia). However, most excess (see Chapter 2). Patients usually wear these
patients are able to achieve good monocular lenses on a temporary basismaybe 1 or 2 years
accommodative skills in each eye even though one and for less time if visin training is also adminis-
eye has strong ocular dominance. tered. We recommend lending plus-lens spectacles
to patients having accommodative problems to
Step 6 provide immediate relief of symptoms; they are
Bi-ocular rock exercises are another way in which particularly useful to relax functional spasm of
to train and equalize monocular accommodative accommodation as found n latent hyperopia,
skills. This is a transition phase between monocular pseudomyopia, and accommodative excess. These
and binocular training. The most practica! way to set lenses also help to modify imbalances n the accom-
up this training s to introduce a vertical dissociating modative-convergence/accommodation (AC/A) and
prism before one eye. Simply, the occluder that was convergence-accommodation/convergence (CA/C)
used in monocular rock is removed and s replaced cross-links (see Chapter 3).
ue usually is
466 Chapter 16
increasing accommodative facility of each eye. increased convergence by exerting extra fusional
Monocular accommodative rock with flipper divergence. If these patients have a sufficiently
lenses is particularly effective. Flipper lenses are large fusional divergence range, they can keep the
available in powers of 0.50 D to 2.50 D so that target clear and single. However, suppose such
they can be selected to match a patient's ski 11 level. patients' fusional divergence is less than adequate
Patients view a watch having a second-hand (a dig- for this particular demand. To diverge the eyes
ital watch also is suitable) and time the number of enough to keep the target single, patients will have
cycles that can be completed within a 1- or 2- to give up some accommodative convergence. In
minute interval, whichever is assigned. Patients doing so, the accommodative response is reduced,
complete as many sets as possible within a 10- and the target appears blurred.
minute training period. A similar explanation can be made for exo-
Another variation that is more entertaining for phoric patients who have trouble in keeping the
patients is called flipper reading. A patient reads target clear and single when plus lenses are intro-
the newspaper, or other material printed in col- duced binocularly. The excessive accommodation
umns, for a 10-minute period. At the end of each results in blurring of the target. Patients during bin-
Une in the column, the lenses are flipped as the ocular accommodative rock may resort to blur,
patient contines reading for comprehension. This because the desire to keep the target single is so
technique builds reflex accommodative facility. No great that they will sacrifice clarity for singleness.
conscious effort to clear the print with each flip Vision training of accommodation helps ver-
should be required. gences, and visin training of vergences helps
Binocular accommodative training should always accommodation. Successful results may depend
include monitoring of suppression (e.g., with vecto- on vergence therapy (see Chapters 13 and 14) to
graphic targets, as in the testing procedure dis- achieve ideal binocular accommodative functions.
cussed in Chapter 2; see Figure 2-18). Binocular
accommodative rock is also discussed in T13.11
andT14.15.
VERGENCES
Vision training with this technique is applicable
to al I eight aforementioned steps. Patients progress Techniques for improving vergence ranges are exten-
through the steps by developing sufficient monoc- sively discussed earlier in this text (eso deviations in
ular amplitude, a large plus and minus range, ade- Chapter 13 and exo deviations in Chapter 14). Fin-
quate speed, quick stimulation and inhibitory ishing concepts of training in cases of esophoria and
phases, equality of monocular functions for each exophoria are discussed in this section, as is visin
eye, ability to perform bi-ocular rock, and normal therapy for hyperphoria and cyclophoria.
binocular facility, and with the ability to meet Bl
and BO vergence demands. Finishing Concepts n
Heterophoria
Other Considerations Fusiona! vergence ranges are expanded through
We have found that most patients with functional visin training, which includes five basic methods
accommodative deficiency can be trained success- of presenting vergence demands: sliding, stepping,
fully within 5 or 6 weeks, assuming good compli- tromboning, jumping, and isometrically bifixating
ance. This guideline applies if there is no significant (see Table 9-4). One convenient home training
vergence anomaly. Accommodative excess, how- instrument for this purpose is the Minitranaglyph
ever, can vary considerably in the strength of the (Figure 16-6). Sliding vergences are performed by
spasm, and training time varies accordingly. slowing and steadily moving the targets in Bl and
Vergence and accommodation are part of a BO directions while sensory fusin is maintained.
reciproca! neurologic system. Vergence problems Step vergence can be performed in several ways:
can have a profound effect on binocular accom- (1) abrupt separation of the targets; (2) use of Bl
modative facility. Take, for example, esophoric and BO flipper prisms; or (3) use of alternating
patients. When minus lenses are introduced binoc- anaglyphic flipper filters (e.g., switching the red fil-
ularly, accommodation causes accommodative ter on the right eye to the red filter on the left eye
convergence to increase. Such patients offset this while green filters switch position from lef t to
Chapter16 467
right). Tromboning can be done by push-ups and gence ranges in both directions should be ampie.
push-aways while fusin s maintained. Jump ver- In a case of fusional vergence deficiency and het-
gence training s done by alternating fixation and erophoria, both fusional convergence and diver -
fusin between a distant target and the Minitrana- gence should be very strong. Vision training should
glyph at near. Isometric fusin training can be per- optimize the four-dimensional zone of clear, sin-
formed by having the patient maintain fusin at gle, comfortable, and efficient binocular visin.
some extreme vergence setting for a specific time
interval (e.g., 1 or 2 minutes).
Any or al I of the visin training methods for pre-
Hyperphoria
senting vergence demands may be necessary for Many of the training techniques for eso deviations
affected patients to achieve adequate vergence (see Chapter 13) and exo deviations (see Chapter
ranges. Better yet, such patients should be given 14) can be applied to training n cases of hyper-
the opportunity for enhancement visin therapy so phoria. During chiastopic fusin, for example,
that the vergence skills improve beyond being Keystone Eccentric Circles (T13.15 and T14.14)
merely adequate (with a score of 3) to being very can be separated vertically by a slight amount to
strong (to a score of 5; see Chapter 2). Moreover, induce a disparity stimulus for vertical vergence.
the ideal s for patients to achieve good vergence Performing these techniques is not easy, and so
ranges without suppression, blur, diplopia, dimin- they should be introduced toward the end of train-
shed stereopsis, fixation disparity, discomfort, ing. We have, however, seen several patients
A
infacility, or lack of stamina. ncrease their vertical vergence by as much as 12
Another concept n the finishing phase of visin with these techniques.
therapy is the visualization of a four-dimensional
model of binocular visin: accommodation, ver- Vertical Step Vergence (T16.24)
gence, fixation disparity, and time (see Chapter 3). Bernell produces a series of vertical step Trana-
A
The first two dimensions n this model apply to glyphs that introduce disparities n 0.25 ncrements
A
clarity and singleness of binocular visin, as n up to 3 (Figure 16-7). This range can be extended
classic graphical analysis. The third dimensin of with the use of lose vertical prisms. Patients fuse
fixation disparity relates to the factor of comfort. each of the four targets in turn, working to improve
The fourth dimensin of time implies the concept speed and accuracy of step vergence while moni-
of visin efficiency. Furthermore, visin therapy toring suppression and stereo perception. To train
results must be durable over time. There is objec- sliding vergence, we recommend rotating the tar-
tive evidence that this is so in most cases of visin gets 90 degrees so that there is no demand on verti-
efficiency dysfunction, when patients are trained to cal vergence. When the red and green images are
22 24
meet a high relase criterion. ~ Also, an impor- fused, the target is slowly rotated to its original posi-
tant concept n the finishing process s that ver- tion of mximum vertical demand. A very gradual
468 Chapter16
ncrease n vertical demand can be smoothly made pensatory effect of a prescribed vertical prism. This
to the mximum limit of fusin. This is possible is particularly true when the prism neutralizes a
because red and green filters are used rather than a vertical fixation disparity (i.e., measuring the asso-
vectographic system that would not allow for rota- ciated vertical phoria). The target should have a
tion of the target. central fusin lock so that a prism would be conser-
vatively prescribed. The criterion of clinical wis-
Varia tions on Vertical dom calis for total compensaron in hyperphoria
Vergence Training (T16.25) (see Table 3-5). When prescribing any prism, clini-
cians are advised to perform the prism confirmation
For other targets without built-in vertical dispari-
procedure discussed in Chapter 3. When a vertical
ties, clinicians can use a small base-up or base-
deviation exceeds 10A, extraocular muscle surgery
down prism (whichever is appropriate for a
could be considered in cases of heterophoria.
patient) to crate a vertical fusin demand. Again,
speed of step vergence is increased. If a lose
prism is quickly flipped from base-up to base- Cyclophoria
down, facility and stamina can be trained. Also, Much of what was said for functional training for
vertical clip-on or Fresnel prisms can be placed on vertical deviations can be said for cyclotorsional
patients' spectacle lenses as an isometric method. deviations, as the two tend to be associated. Prism
Most standard fixation disparity targets are excel- compensation, however, s not feasible for cyclo-
lent for training vertical vergences in this manner. phoria. Vision training is the bestand often the
As vertical prism demand is increased, suppression onlyoption. Many targets can be used in this
and fixation disparity can be evaluated. The ult- manner. For example, Keystone Eccentric Circles
mate vertical ranges may be fairly small, perhaps can be rotated during orthopic (T13.15) or chias-
only several prism diopters; nevertheless, visin topic (T14.14) fusin to stimulate incyclovergence
trainng may help patients to cope with a problem or excyclovergence. The major amblyoscope s the
caused by hyperphoria. most ideal instrument for this type of training. Tor-
Improvement of horizontal vergence efficiency sional amplitudes can be increased for some
usually helps patients to cope with a vertical devi- patients, in our experience, up to 25 degrees.
ation (see Case 2 in Chapter 15). Once the hori- Besides visin training techniques, surgery is the
zontal ranges begin to expand, a vertical demand only other method for treatment of these problems.
is introduced (e.g., a lose base-down prism along However, it s not advisable in most heterophoric
with Bl and BO demands). cases. Cyclophoric problems often are alleviated
Vertical vergence training has limits, however, after horizontal and vertical vergences become
and affected patients may have to rely on the com- efficient by means of visin therapy.
Chapter16 469
Symptomatic Orthophoria pose (see Figure 13-1 b). The figure has an overall
Vergence efficiency therapy is sometimes important disparity of 6A at 40 cm. When the central win-
for orthophoric patients. This is particularly true if dows are aligned, the peripherally fused window
the fusional vergence ranges are decreased and appears to float forward. The first step s for the
vergence facility and stamina are poor. Clinicians patient to track along the spiral as quickly as possi-
may wonder why patients who are orthophoric at ble from the central window to the peripheral win-
far and near have symptoms pathognomonic of ver- dow and back again severa! times. The suppression
gence anomalies. Testing with the altrnate cover controls n the windows should be monitored. The
test in conjunction with pencil push-ups can some- goal s to develop the most vivid sense of depth of
times answer this enigmatic question. This testing the target so that t floats maximally from the plae
procedure of Griffin's is called the kinetic cover of the instrument. Continuing to move the eyes,
test, as opposed to a regular statc cover test. the patient walks away from the target, noting the
Orthophoric patients (found with usual testing pro- degree of depth, and then walks toward the target.
cedures) are only orthophoric under static viewing If a foveal clue ever disappears, the patient imme-
conditions. People, however, live under dynamic diately breaks the suppression before proceeding,
viewing conditions and not in a static world. The by blinking, pointing, and ncreasing the target
kinetic cover test reveis how orthophoric patients illumination when feasible. This process contines
will momentarily have an exo deviation as fixation with varying BO and Bl vergence demands. The
is changed from far to near and have an eso devia- patient should try to improve his or her sense of
tion when fixation changes from near to far. Ortho- depth at various distances and vergence demands
phoric patients may have binocular symptoms if over a 10-minute period. A second step requires
there are inadequate vergence ranges (see Figure 3- the patient to report the subtle depth clues of each
20). All vergence and accommodative ranges, letter along the spiral figure. Each letter should be
including facility and stamina, should be expanded perceived either nearer, farther, or at the plae of
with visin training in these cases of a "tight" zone the target. This sense of subtle stereopsis s trained
of clear, single binocular visin. by ncreasing response speed and accuracy, target
distance, and vergence demands. A third step
would be to project the Spriangle at far on a metal-
lic or vinyl screen (to preserve polarization) and
STEREOPSIS repeat the previous steps.
Stereopsis represents the highest level of binocular Another effective vectographic technique for
visin. There is little doubt n the minds of experi- enhancing stereopsis uses a combination of the acu-
enced clinicians that stereoacuity can be improved ity-suppression slide (nonvariable) and the Quoits
with visin therapy. Improvement can be due to slides (variable) (see Figure 13-11h and 13-11a,
the successful results of antisuppression training, respectively). Both Vectograms are placed together
cure of amblyopia, elimination of anomalous reti- in a transparent slide holder held by the therapist.
nal correspondence, reduction or elimination of The patient views these targets through polarized fil-
fixation disparity, and ncreased perceptual aware- ters from a distance of approximately 2 m. Quoits
ness of binocular depth. Wittenberg25 reported a slides are disparated slowly in the BO direction by a
study conducted with the late Dr. Frederick Brock slight amount. The patient always bifixates the sup-
and indicated that "stereoscopic acuity had defi- pression controls on the nonvariable slide and notes
nitely improved n the trained group." Before a the distance at which the fused Quoits appear to
patient s released from a visin therapy program, float forward in space. The stereo percept can be
stereoacuity should be maximally enhanced f t quite dramatic. The therapist contines to introduce
remains deficient. BO and Bl demands slowly without allowing the
Quoits image to double. The patient estimates the
mximum distance at which the image appears to
Vectogram Stereo float n both fore and aft directions at a particular
Enhancement (T16.26) distance from the targets. Both the patient and ther-
A number of Vectograms are beautifully designed apist work together to increase the distance at
for enhancing a patient's sense of stereopsis. The which the Quoits target appears to float off the
Spriangle is one of our favorite targets for this pur- plae of the holder. This stereo awareness technique
470 Chapter16
should be attempted at various distances from the computer gives an analysis of the "hit rate" for
target holder. For sometric vergence training, differ- each task so that progress can be charted.
ent lose prism demands can be attached to the Improved stereoacuity s often the result when
patient's spectacles. sensory and motor fusin have been improved
An interesting variation of this technique with with visin therapy. Al I treatment methods dis-
Quoits is as follows: Have the patient look through cussed in the previous chapters should be consid-
the center of the Quoits while holding them in a ered and used as needed. Furthermore, good
clear slide holder. The Vectogram s atarm's length, stereoacuity s an ndicator of success in visin
and the patient fixates a Marsden ball 1 or 2 m therapy for persons with binocular anomalies. In
away such that the ball is seen in the center of the many cases, poor stereoacuity (or, possibly, lack of
fused Quoits. The therapist next disparates the stereoacuity) in the strabismic patient can be trans-
Quoits approximately 2 An the Bl direction. This formed into good stereoacuity when the strabismus
creates an uncrossed disparity on Panum's rea s cured. In heterophoria cases, superior stereoacu-
when the patient bifixates the ball. The fused ity represents the touchstone of success when effi-
Quoits should appear to be floating away, back to cient visual skills have been achieved.
the plae of the Marsden ball, with exact disparity
conditions. The therapist then swings the ball in a
fore-and-aft direction. The patient should be able CASE EXAMPLES
to perceive the ball "going through the Quoits"
toward him or her and then see it swing back Case 1: Eye
through the Quoits as it travels farther away. This is Movement Dysfunctions
fascinating to children, as well as adults, as though This 18-year-old woman presented with symptoms
something magical s happening. The swinging ball of sharp pain in her left eye and headaches.26 She
s a form of tromboning exercise n this instance. had noticed these symptoms for many months.
For combining this accommodative training tech- They were consistent in that they would begin after
nique with pursuit training, the ball can be swung approximately 15 minutes of reading. The symp-
in a circular fashion so that the patient has to move toms subsided, however, in approximately 30 min-
the hand-held Quoits in synchrony with the ball to utes after cessation of reading. She also reported
keep the ball centered n the Vectogram. Besides skipping lines and losing her place while reading.
tromboning for accommodation and following the The patient was a freshman in college and had a
ball for pursuits, prism can be worn for vergence history of being an excellent reader, but recently
training while the patient is experiencing this novel her symptoms had affected her reading perfor-
technique, for enhanced awareness of stereopsis. mance. She mentioned that she was able to read
on a college level when she was n jnior high
school.
Computer Stereo At the first visit, further history indicated that the
Enhancement (T16.27) patient had had an eye examination 1 year previ-
Computer Orthoptics by Dr. Cooper (see AppendixJ) ously. Accommodative rock training was recom-
uses random dot stereograms to genrate stereo mended at that time but was never carried out. She
perception in a game format (T13.16). The stereo- reported that her mother has intermittent exotro-
scopic target can be seen in only one of four ran- pia. There was no other remarkable eye or health
dom positions on the screen: up, down, left, and history n her family.
right. The patient indicates the target's position by Subjective refraction was as follows:
rapidly moving a joystick (or directional arrows) in
the appropriate direction. Initially, without Bl or Oculus dexter (OD): plano -0.25 x 180
BO demand, the patient builds speed of stereo per- 20/15 (6/4.5)
ception. The next step is to change fixation dis- Oculus sinister (OS): plano
tance by walking away, holding the joystick, and 20/15 (6/4.5)
continuing the process. Next, the targets are dis- The patient had 0.5A exophoria at far and 5A
parated Bl and BO within the patient's range of exophoria at near. Bl to breakpoint at 6 m was 5A
fusional vergence at various speeds. The therapist and to recovery was 3 A; Bl to blurpoint at 40 cm
programs these parameters into the computer. The was 10A, to breakpoint 16A, and to recovery 4A. BO
Chapter16 471
T
F
R
C
C
N X
Z R C
X N A
R H
F Z U
Y
K o
S T
K
B * X
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 Z N
H O
L
A R
T X F
B S
P
A
A A
to blurpoint at 6 m was 4 , to breakpoint 9 , and to monocular pencil push-ups to work on accommo-
A A
recovery 8 ; BO to blurpoint at 40 cm was 12 , to dative amplitude) for 5 minutes daily.
A A
breakpoint 18 , and to recovery 6 . Fusional ver- The second visit occurred approximately 2
gence ranges were considered to be slightly below months later. Accommodative facility was tested
normal. Her nearpoint of convergence (NPC) was and found to be 21 cycles per minute OD, 19 cycles
normal, howeverapproximately 2 cm from the per minute OS, and 17 cycles per minute binocu-
bridge of the nose. larly, using 2.50-D lenses. BO to blurpoint on the
A
Accommodative amplitude of the right eye was Vodnoy Aperture-Rule Trainer was 20 . Home train-
11.00 D but for the left eye was only 8.50 D. NRA ing was prescribed as follows: (1) monocular pencil
was +1.75 D, and positive relative accommodation push-ups, each eye, 5 minutes per day; (2) binocu-
-5.25 D. Accommodative facility with 2.00 D lar pencil push-ups, 5 minutes per day; (3) accom-
was 15 cycles per minute, OD, OS, and binocu- modative rock using 2.50 D OD and OS, and
larly. Accommodative ski lis were considered nor- binocularly, 5 minutes per day; and (4) Landolt C
mal, with the exception of insufficient ampNtude charts (for identification of the direction of the open
of the left eye. The cause of less accommodative portion of Cs) and starlike charts for saccadic eye
amplitude of the left eye could not be explained movement training for 5 minutes daily (Figure 16-9).
on any organic basis. The third visit was 1 week later, and the patient
The patient had problems with saccadic eye reported that she was performing her home train-
movements. She scored an equivalent age of 10 ing faithfully, with no problems accomplishing the
years on the Pierce Saccade Test (see Chapter 2). tasks except for occasionally having difficulty see-
Problems with position maintenance and saccadic ing clearly with the plus lenses during accommo-
eye movements could be seen in the results of Eye- dative rock. She was able to converge more than
A
Trac testing (Figure 16-8). 33 with clear, single visin on the Aperture-Rule
A
To summarize, on the first visit the patient Trainer, and she could diverge 16 with clear, sin-
[seemed to have a significant problem with sae- gle visin with Vectograms. Saccadic eye move-
teadle eye movements, possible accommodative ments were normal on the Pierce Saccade Test.
[Bufficiency of the left eye, and reduced fusional Prescribed home training consisted of the follow-
Iwrgence ranges. Prescribed home visin therapy ng: (1) Keystone Eccentric Greles combined with
Iconsisted of accommodative trombn i ng (e.g., farpoint Hart Chart for 5 minutes per day (for chi-
472 Chapter16
ment and the number of visual symptoms reported meet the expectations of parents and teachers. As
during the act of reading; this s a surprising result, the visual demands associated with lifelong educa-
as reading achievement is known to be influenced tion increase, we anticpate a commensurate
by many factors (e.g., ntelligence quotient). There increase in the number of patients needing and
is, however, a preponderance of evidence in the lit- wanting visin therapy.
erature that shows that heterophoric, fusional ver- It s a common clinical experience to examine
gence, and accommodative problems occur more patients for whom learning to read has been a slow
frequently among poor readers as compared with and difficult process; poor reading skills and ability
peers who read normally.30"32 One particularly are the primary concerns initiating the examina-
interesting ophthalmologic report regarding improve- tion. Detailed information about the patient's eye
ment in reading performance after visin training, movements during the process of reading offers
by Haddad et al.,33 describes a series of 73 children valuable insights about reading efficiency, the
referred for visin examinations because of reading information-processing strategy that the reader has
difficulties. Fifty-eight percent of the total group adopted, and the impact of VSE on the reading act.
were considered to have "dyslexia," because they Even though eye movement recording systems
reported excessive reversal confusin on letters and have been marketed to educators, the educators
small words. This does not appear to be a rigorous often do not feel capable of or comfortable inter-
definition of dyslexia, n our opinin, and more for- preting the results of such analysis. For these rea-
mal testing34 is recommended for future investiga- sons, we believe an analysis of reading eye
tions regarding dyslexia. Nevertheless, more than movements deserves to be a service routinely
half of the "dyslexic" children had deficient fusional offered by clinicians specializing n pediatric
amplitudes by clinical testing. A visin training pro- optometry and visin therapy. This analysis can
gram designed to increase fusional vergences, help parents, patients, and educators decide how
improve the NPC, and break suppression was initi- to proceed n remediating reading difficulties.
ated in cases of fusional deficiency. Improvements
in attention and reading performance (length of
time of uninterrupted reading) were reported after Visagraph Testing of
resolution of the fusional deficiency in both the des- Reading Eye Movements
ignated dyslexic and nondyslexic children. These The Visagraph II Eye Movement Recording System
authors concluded that the visin training did s a modified Ober 2 infrared monitor composed of
improve reading performance.33 hardware and software components used primanly
Griffin35 discussed early prediction of dyslexia to record and analyze the fine structure of reading
with visual skills efficiency (VSE) testing. His pre- eye movements. The system includes goggles that
vious studies on older children showed little or no emit nfrared light that s reflected off the cornea
correlation between dyslexia and VSE (and even and is picked up by two horizontal sensors for each
visual-perceptual information-processing skills). In eye that sample eye positions 60 times per second.
infants and young children, however, significant As the eyes move across a page, the amount of light
relations were found, including pursuits, NPC, ste- falling on the sensors vares, and this variation is
reopsis, visual memory, and visual-motor integra- analyzed electronically. The goggles are connected
tion. It appears that critics of visin therapy have to a junction box that feeds into a PC loaded with
been looking at the wrong age group when dis- software designed to analyze and dsplay the eye
avowing the relation between visin problems movements. After the goggles are adjusted properly
and dyslexia. Further elaboraron can be found in and set to the patent's near interpupillary distance,
Griffin et al.36 regarding management of reading the patient silently reads the printed text in a free-
dysfunction. space environment. Testing is done using reading
We frequently see students who suddenly have material that is grade-level-appropriate for the
reading improvement after a visin therapy pro- patient's sight vocabulary. Test passages are avail-
gram for inefficient visual skills. We believe these able for eight grade levisgrades 1-6, middle
clinical observations will eventually be confirmed school, and high school. Ten true-or-false compre-
by formal, properly controlled, clinical triis. Then, hension questions are asked after the recording has
students of al I ages will likely be referred for evalu- been made to ensure that the passage was basically
ation of VSE when reading performance does not understood. The validity criterion requires that at
Chapter16 475
, | i J i
1.5
14% Countable unes in text 9
109 Lines found 10
80% Saccades in Return Sweeps 21
0.973 Anomalies (Fix/Regr/Both) 5/4/6
Subject information
Grade: 3 Filename : JOG-28-Q.rec
ame : Guiiia
Sex : Recorded : 91 4/99 12:46
Class : Born :
Director/ : C:\VISA\REC
School : Examiner :
FIGURE 16-12The Visagraph profile of reading eye movements. This third-grade patient read a second-grade-level selection with 80% compre-
hension, 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 first-
grade 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 simula-
tion. 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.
least 70% of questions be answered correctly. If this sages have shown acceptable reliability between
level is not achieved, then a lower grade-level pas- the second and third reading selection, but neither
sage s used for retesting. The Visagraph analysis correlates well with the first recording.37'38 For this
software reports the eye movement characteristics reason, we recommend obtaining at least two
relative to reading a passage of 100 words and
compares the reader's performance with national
grade-level normative data.
Most school-aged patients experience some
level of test anxiety when initially performing a
Visagraph eye movement recording. Some rush
through the selection without adequate compre-
hension. Others intentionally read slowly and
reread portions, trying to avoid errors. Test-retest
reliability studies on grade-level-equivalent pas-
recordings to establish a patient's reading eye
movement profile.
The following features are the specific ndices of
reading performance that are presented as a read-
ing profile (Figure 16-12). Grade-level perfor-
mance is scaled across the top of the graph.
Fixations/100 words refers to the number of
times the eyes actually stop or pause for a time
interval so that decoding can take place. Decoding
does not occur when the eyes are moving from
one position in print to another. Both forward fixa-
tions and regressive fixations are counted in this
ndex. Mature readers typically make fewer fixa-
tions than do beginning readers and, generally,
there is an inverse linear relationship between
grade level and the number of fixations.
Regressions/100 words refers to the number of
backward or regressive eye movements the student
476 Chapter16
477
Behaviors: Please rate the child on the following tems. Place a number in the blank to the left of
____ 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 effi- tion. If the patient has decoding
ciency ndex, is either within one grade difficulties (e.g., does not know the
level of the present school grade or higher. words), then a lower
No general management recommendations
need to be made n these cases.
Behaviors: Please rate the child on thefollowing tems. Place a number in the blank to the left of
____ 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 eff- grade-level passage s chosen until fluency s
ciency ndex, is either within one grade demonstrated. An altrnate selection at the
level of the present school grade or higher. fluency level then s chosen for Visagraph
No general management recommendations testing, and the patient reads this silently. The
need to be made n these cases. reading rate or grade-level equivalent is
more than 1 year lower than the patient's
Inefficient Reader Profile grade placement. These patients often have a
An inefficient reading strategy is ndicated under profile that s consistently, across-the-board
the following conditions: lower than their grade placement, which may
be due to reading habits that have not
1. The grade-level passage needed for success- changed with experience. The patient reads
ful testing s more than 1 year below the successfully but slowly. Some subvocalize
school-grade placement. The fluency level s (subcortical vocalizaron) when reading,
determined prior to Visagraph testing by hav- which limits reading speed. These patients do
ing the patient read aloud a grade-level selec- not have a history of signs and symptoms that
tion. If the patient has decoding difficulties indcate a learning disabilty (Figure 16-13;
(e.g., does not know the words), then a lower see also Appendx B). There s no evdence of
478 Chapter16
Motor Integration Test, the Rosner Test of Auditory 4. VSE dysfuncton is suggested by cross-corre-
Analysis Skills, and The Dyslexia Screener (TDS). lation of less than 0.950 when there s a
(See Appendix J.) lapse n vergence algnment. For example,
In the management of dyslexia, the optometrist in moving from the end of one Une to the
is one member of the remedial team. The specialist beginning of another, a patient havng a
in visin therapy should supervise the remediation large heterophoria at near may show ds-
of any visual efficiency skills and visual perceptual junctve eye movements in the record. How-
dysfunctions. Taylor Associates also offers two indi- ever, a common cause of a low correlaton
vidual home-based computer programs on CD- is the improper alignment of the Visagraph
ROMWord Memory, to help build sight words, goggles before the eyes. When we find a
and D-Code, to improve phonetic analysis. These low cross-correlation, we readjust the inter-
software products faciltate the transition from pupillary distance of the goggles and overall
visual skills training to remedial reading instruc- goggle placement, repeat the recording, and
tion. The dyslexic reader usually needs to work directly inspect the graphical recording for
with a reading specialist who is trained n teaching disjunctive eye movements.
children who have learning disabilities. Examples
VSE dysfunction can be found in cases falling n
of commonly used Orton-Gillingham multisensory
the aforementioned descriptions and can signifi-
programs, in schools and prvate tutoring settings,
cantly compromise reading comfort, efficiency,
designed for teaching dyslexic students to read are
and performance. Even patients who show effi-
the Lindamood-Bell Program, the Slingerling Pro-
cient reading on the Visagraph and are not identi-
gram, and Project Read. Many prvate educatonal
fied as having a reading dysfunction can manifest
specialists and resource specalists n public
tracking, focusing, or fusiona! dysfunctions that
schools use a variety of approaches and talor a
limit superior reading performance. Many of these
program for the nterests and ablities of the indi-
cases are overlooked because reading problems
vidual student.
are not a presenting problem, except possibly for
specific visual symptoms or patterns of reading
Visual Skills Deficiency Profle avoidance. Often the greatest gains in reading effi-
Deficencies in VSE can manifest during the act of ciency by Visagraph assessment are realized after a
reading even with a short paragraph of 100 words. patient completes a visin therapy program for
Features of a Visagraph profile and eye movement visual skills deficiencies. The dyslexic reader also
graphical recording that indcate VSE dysfunction usually benefits from visin therapy when visual
are as follows: skills dysfunctions are abated. Reading comfort
and efficiency frequently are ncreased, but perfor-
1. More than 20 saccades on return sweeps
mance gains are typically not as impressive due to
for 10 recorded lnes of prnt and missed
the decoding dysfunctions characteristic of dyslex-
unes due to faulty saccades or excessive
cs. Visual skills therapy s not expected to cure
head movements are ndications of sac-
dyslexia but usually does significantly increase
cadic tracking dysfunctions.
reading comfort and efficiency (Figure 16-14).33
2. The simulation of reading eye movements is
a men option showing the text on screen
and a bouncing ball that reflects the fixation Computers and Visual
pattern on the paragraph. This simulation Skills Efficiency
may indcate tracking abnormalties on Many high-tech industries place intense visual
return sweeps (e.g., dropping the eyes down demands on their workers. Quality control of
and moving backward across a line of print microchips, for example, requires workers to
to find the beginning word in the line or develop new levis of visual skills (e.g., increased
missing the initial words n several Unes). attention and critical viewing for long periods).
3. A high number of anomalies (10 or more), Microcomputers now are found on most office
for which the recording indcales asymme- desks and in most homes. Accompanying these
tres, s ndicative of VSE dysfunction. This technologic advances are some undesirable prob-
ndex s senstive to lapses n vergence lems, one of which is asthenopia. Certain aspects
algnment and blinks. of work performance, particularly those using
480 Chapter16
:s^ :::
of Fixation (seo) 0. 25 0.26 0.27
H
-
Rale with Comprehension (words/min) 138 158
Relative Efficiency Grade Leve) 0.75 0.93
Equivalen! 3.1
Diractional Attack 9% Countable lines n text 7
Rale adj. for Rereading (words/min) 138 Lines found 7 FIGURE 16-14Visagraph profile
Comprehension Questions Corred 80% Saccades in Return Sweeps 11 after 2 months of visin therapy. In the
Cross Correlation 0.968 Anomalies (Fix/Regr/Both) 3/2/5 patient who presentad with the Visa-
graph profile shown in Figure 16-12,
saccadic tracking deficiency and
Subject information
accommodative infacility were diag-
ame : Guilla Grade: 3 Filename : JOG-29-O.rec nosed. She was successfully treated
Class : Bom : 10/16/1989 Sex : F Recorded : 11/02/1999 17:53 with 2 months of mostly home visin
School : Directory : C:\WINVISA\REC training techniques. The post-therapy
Examinar : Visagraph profile demonstrated that
all ndices of reading performance
Text nformation Countable part statistics mproved, even using third-grade
Filename : C:\WINVISA\TEXTS\amer_eng\t-3-29.txt No of lines : 7
reading material. Her overall reading
efficiency had increased from a 1.5
Tille: Stamps 3-29 No of words: 50
grade-level equivalent to 3.1, and her
Answers : YNNYYNYNNN No of questions : 10 Av. word length : 4.2
parents and teacher noticed the differ-
Norms used : TAYLOR.NOR Correct answere 8
ence in her schoolwork.
depth perception, are facilitated by normal binoc- based visin training are Computerized Aided
ular visin.40 More than half of the computer- Vision Therapy by Dr. Gary Vogel (from Bernell) and
related symptoms of eye care patients stem from the Home Therapy System (HIS) by Drs. Jeffrey Coo-
deficiencies n accommodation and convergence.2 per and Rodney Bortel (from Midwest Vision Ther-
The need for high-quality binocular skills is evi- apy Equipment Company, Inc.). (See Appendix J.)
dent in these visual environments. Nearpoint We have had extensive experience, mostly suc-
lenses for computer use and, often, visin training cessful, with the HTS software, a PC-based appli-
usually resolve patients' symptoms. cation, in the academic clinical setting, in prvate
It appears likely that the joint influences of high- practice, and as a supplement to home visin
tech industries and the drive toward universal therapy programs. There is an institutional or
usage of computers will continu to genrate office CD that can track the progress of several
increasing demands for binocular visin services. patients and a home-based CD for individual use.
This technologic revolution has inspired the col- Many patients aged 8 and older, including adults,
laboration of visin scientists and optometric prac- find the exercises challenging and sufficiently
titioners to solve new problems regarding ocular gamelike to engage their nterest for 20-30 min-
comfort and visin efficiency. Many optometry utes of visin training. Patient progress s easily
schools and prvate practices offer some form of monitored with the reporting functions of the soft-
video display terminal assessment, and the need ware; the training goals are identified clearly. The
for visin therapy s growing. implementation of the vergence training and
Possibly the most important and far-reaching accommodative rock modules seems particularly
development n the field of visin therapy in the last effective. Patients having visin efficiency dys-
10 years has been the emergence of a number of functions and ntermittent strabismus at near who
computer-based programs to train visual skills. Two appear to be unmotivated by standard techniques
well-developed and readily available software prod- are particularly good candidates for computerized
ucts that can be used for either n-office or home- visin training.
Chapter16 481
HTS must be prescribed by and purchased from tory of performance can be viewed for each mod-
an eye doctor. The program can be opened only ule by choosing the performance review option.
100 times (i.e., 100 visin training sessions) to These performance charts can be transferred to a
ensure doctor control and enforce monitoring. Five disk and brought to the doctor's office for review
visual efficiency skills are trained: gross saccades, and progress consultation.
smooth pursuits, accommodative facility, conver- In-office HTS, and other similar programs, can be
gence ranges, and divergence ranges at 16 inches easily mplemented by a trained assistant, thereby
Figure 16-15). Each training module requires the allowing the doctor to double-schedule patients or
patient to use either the four arrow keys or a joy- perform other tasks. Some doctors have set up a
stick to indcate a response to a specific visual small computer laboratory in a visin therapy room
stimulus. For example, in the jump duction (more and ncreased staffing, thereby substantially increas-
correctly, step vergence) module, the patient wears ing their patient flow. Internet versions of computer-
red-blue goggles and indicates the position on the ized visin training will soon be available, which
screen (up, down, left, right) of a red-blue random should make this form of visin efficiency training
dot stereogram seen in three-dimensional relief, if more widely available to the doctor's office, the
successfully fused. The stimuli are alternated with patient's home, and even school classrooms under a
increasing amounts of Bl and BO disparation until Consulting doctor's supervisin.
the patient can no longer fuse the mages or makes
mistakes n determining the location of the three-
dimensional image. Vergence demand then s Sports Vision
decreased until the hit rate with the arrow keys Binocular visin therapy is an integral part of the
exceeds chance level, indicating that fusin has emerging specialty of sports visin. Several binocular
been regained, and then vergence demand is visual skills have been reported to be superior n ath-
increased again. letes, particularly players of ball games: These
41
All modules can be run n the automatic mode, include speed and accuracy of ocular motility, far-
42 43 44
in which the sequence of training tasks and times point vergence facility, static depth perception, '
45
is predetermined. Each also can be run in the man- and dynamic stereopsis. Studies have shown that all
ual mode, n which the doctor determines which these skills can be trained to higher levis of perfor-
46
skills will be trained, their sequence, and the time mance. Most outstanding athletes do not have sig-
interval for each module. nificant visual dysfunctions but, when an athlete does
The accommodative rock module requires the have them, doctors render care with the hope that
patient to wear red-blue glasses and hold one of six athletic performance will improve.
pairs of prepared lenses in front of the eyes; one lens Clnica! application in sports visin extends
is minus, thus stimulating accommodation, and the beyond the classic concept of visin therapy for
other is plus power, thereby relaxing accommoda- remediation. A growing number of optometrists pro-
tion. This is bi-ocular training, because sensory vide enhancement programs in visin therapy. They
fusin would be blocked by the induced ani- train amateur and professional athletes having nor-
sometropia. Red and blue targets are alternated on mal binocular visin and perceptual-motor skills
the screen as the patient indicates with the arrow and help them to attain superior levis with the
keys the location of a small dot. The program sum- ntent that this training will faciltate ncreased on-
mates the amount of time a patient requires to focus the-feld sports performance. The glamour aside,
and respond in switching from one eye's target to this new direction does indeed have a serious
the other; this yields an accommodative facility basisthat of helping individuis to overeme their
ndex in cycles per minute. The highest set of lenses limitations and achieve their dreams. One of our
for this training s +2.00 D and -5.00 D. patients, for example, improved her softball batting
Motivational and monitoring features are built average from .250 to .750 as a result of visin
into the HTS program. After a module's time inter- enhancement therapy that included classic visin
val has expired, the patient s given mmediate therapy approaches along with eye-hand coordina-
feedback regarding performance n relationship to tion and peripheral awareness training. Controlled
the module goal. The skill level achieved in the studies of visin training and athletic skills are
previous session also is displayed for comparison. needed, however, to confirm the hopes of many
A graphical presentation of the patient's entire his- 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 in-
tial session.
Chapter16 483
TECHNIQUES
Introduction
PartThree's ntention s to provide systematic labo- training instructions for office and home can be
ratory-like nstruction n binocular training tech- reproduced or modified as desired. The compact
niques for optometric practitioners, students, and disk can be downloaded into the clinician's com-
visin therapists. This part s coordinated with Parts puter and modified as well. Instructions for office
One and Two, so the clinician wili find it to be a visin training can be orchestrated and modified
practical guide to visin training. Theory and as necessary by prescribng doctors and visin
research citations are not included, as they are therapists during office visin therapy sessions. For
amply covered in the previous chapters. Only the home visin therapy, the suggested instructions
most frequently used visin training techniques are are appropriately written for older children and
presented n PartThree, and they are applicable to adults. Younger children must have these instruc-
therapy for efficient visual skills to achieve maxi- tions read to them by parents or other helpers at
mal performance n school, work, and play. home.
The first set of techniques (in Chapter 17) is for eso Most of the instructions, whether for home or
deviations, the second set (n Chapter 18) s for exo office therapy, are written so that they are easily
deviations, and the third set (n Chapter 19) is for understood by office therapists and assistants,
saccades, pursuits, and accommodation. Chapter 20 other health professionals providing visin ther-
ncludes recommended sequences for visin training apy, and home helpers. Instructions for some
techniques based on diagnostic categories. Also in training techniques may appear similar but,
Chapter 20 are comments on practice management because each technique is intended to stand
of visin therapy in various clinical settings. alone, some redundancy s necessary. All profes-
Each visin training technique (designated by a sional members of the visin therapy team are
double number preceded by T) s discussed n the encouraged to review, extensively and frequently,
following format: purposes, equipment, recom- Parts One and Two of this text to continu con-
mended office visin training instructions, and necting the theoretic concepts with applied clini-
home visin training instructions. These visin cal techniques.
487
chapter 17 / Vision Training for Eso Deviations
See Chapter 13 for further discussions of the tech- or the therapist, or both, are demonstrating the use
niques addressed n this chapter and for other of the instrument.
techniques and therapies for eso deviations.
1. "I want you to put the tip of your nose on
the edge so that the mirrors are before
both eyes."
MIRROR STEREOSCOPE 2. "The fusible targets, one for each eye, are
(T13.2,114.4) placed so that you should be able to see
both at the same time." Have the patient
Purpose start with an ortho demand as shown by
The main purpose of using the Bernell Mirror Ste- O, llustrated in Figure 1 7-1.
reoscope s to build fusional vergence ranges 3. "Try to move the arms of the Stereoscope
while monitoring suppression. In eso deviations, closer together while maintaining fusin
the emphasis is on fusional divergence. Stereopsis that s, the target doesn't double but
may be improved when stereograms are fused remains single as you move the instru-
through large ranges of base-in (Bl) and base-out ment's arms closer together."
(BO) demands. 4. "Look at the numbered place on the mea-
suring rule. This represents the amount
Equipment your eyes converged accurately without
seeing double or suppressing, meaning
This technique requires the use of the Bernell Mir-
that all parts of the fused image could be
ror Stereoscope (see Figure 13-1),
seen at all times during the moving of the
arms of the instrument."
Recommended Office Vision 5. "Continu moving the arms slowly closer
Training Instructions together and report whether the fused
The Mirror Stereoscope has two mirrors and is image becomes blurred."
shaped in the form of the letter W; prismatic 6. "Even if there is blurring, continu moving
changes can be varied from approximately 40 A Bl the arms closer together and report when
to 50A BO. the target image becomes doubled."
Recommended oral instructions follow. Although 7. "After the doubling, move the arms of the
these oral instructions are given to the patient, you instrument from the narrow position to a
*
11111111111111111ti111111111
wider position and try to recapture the you were nstructed during office visin
single fused mage." training. Keep changing the separation
8. "Continu moving the arms of the instru- distance until you can fuse the targets eas-
ment farther apart until there is blurring ly n that position.
and doubling. This is training your eyes to 11. Once you can fuse the targets easily,
diverge after having been converged." move the arms of the instrument farther
9. "When there s a good convergence range apart to make your eyes diverge. Try to
and also for divergence as a result of train keep the fused image clear and single.
ing, try to notice any apparent change of
size of the fused mage of the target. The
target may appear to become smaller as
DUAL POLACHROME ILLUMINATED
you converge and larger as you diverge."
TRAINER VECTOGRAMS AND
10. "As you perform this exercise, always
monitor suppression, to ensure that all
TRANAGLYPHS FOR DIVERGENCE
portions of the target are visible, and keep TRAINING AT NEAR (T13.8)
the depth perception at all times, espe- Purposes
cial ly when diverging to overeme your One purpose of the Dual Polachrome Illuminated
eso deviation." Trainer Vectograms and Tranaglyphs for divergence
training at near is to train sliding fusiona! vergence
Home Vision Training (Bl). Additionally, the technique helps to monitor for
Instructions suppression during ncreased Bl demands. Through
the training, patients can develop second-degree
1. Set up the instrument as you were taught
and third-degree fusin skills and strengthen step
in the office training session.
vergences.
2. Ensure that t forms the letter W and that
the arms of the instrument are supported
by the stand. Equipment
3. Place a target that depicts an L label in Equipment includes the Dual Polachrome Illumi-
the slot of the left panel and the target nated Trainer, crossed polarizing viewers, and a
with an R label n the panel on the right- selected Vectogram (vecto), listed here n approxi-
hand side. mate order of difficulty (see Figure 13-11): Quoits
4. Seprate the central panels enough so (two-piece); Clown (two-piece); Mother Goose
that both targets are seen when looking (two-piece); Spirangle (two-piece); Figure 8 (one-
nto the mirrors. piece); and the Chicago Skyline (two-piece).
5. If the targets are not level, adjust them by
raising or lowering one or the other.
6. Position the arms of the instrument so that Recommended Office Vision
the separation equals approximately zero Training Instructions
(0) on each side. Place the chosen vecto (e.g., starting with Quoits)
7. Try to fuse the targets at this setting and into the slots of the Polachrome Illuminated Trainer
see the mage ciearly. at zero demand. Place the target squarely n front of
8. You will know that the targets are fused your patient so that the vecto is at a viewing dis-
together by seeing all parts of each pic- tance of 40 cm (16 in.). Have your patient wear
ture. If you suppress one eye, part of the crossed polarizing filters. Demnstrate the look of
target before that eye will be missing. suppression by alternately covering the patient's
9. You will also know that you are fusing the eyes and asking your patient to report what image
targets by being able to see depth n the disappears. Tell your patient to report whether sup-
fused image. This s known as stereopsis. pression ever occurs during the activity. Instruct the
One circle of the mage should appear to patient to keep the target single and clear as long as
be closer. possible. Remind the patient of how fusing feels
10. If you have trouble with fusing the targets, (e.g., "Eyes feel like they are working"). Ask your
adjust the separation between them, as patient to report any proprioceptive feelings (sensa-
492 Chapter17
AA
B
DA Pointer
with
AP2
and
1&2 double
aperture
Farther
Portion
Nearer Portion of
of Rule Rule
FIGURE 17-3The Aperture-Rule Trainer with double aperture n
8 Pointer
with
place for base-in demand training. (Courtesy of Bernell Corp.) API
10 and
double
aperture
11
Equipment
The Aperture-Rule Trainer with the double aperture 12
is used (Figures 1 7-3 and 1 7-4; see also Figures
13-13through 13-15). Fusin O
Target AP
1. "Place the double aperture slide on posi- training. Remember to ensure clear, single
tion DA on the rule." visin with depth perception and no sup-
2. "Put the first demonstration card on posi- pression. Also, try to control any slight
tion A for alignment check, and put your misalignment of the eyes while trying to
nose on the front end of the Aperture-Rule diverge them. The suppression clues (e.g.,
Trainer. Be sure you can see the target with dot and plus sign) should be exactly above
each eye, so that your eyes, the apertures, or below each other. If one of the symbols
and the target are n proper alignment." is slightly displaced to the right or left of
3. "Remove the first demonstration card, put the other, this slight error or vergence is
the suppression monitoring (demonstration) called fixation disparity. This visin train-
card on position A, and report whether you ing technique will help you to work on
can see the suppression clues (e.g., the R that also."
and the L). If there is no suppression, pro-
ceed to training with card API." Home Vision Training
4. "Place the AP1 card at position O and the
Instructions
slider with the double aperture at posi-
tions 1 and 2." The instructions for home visin training are essen-
tially the same as those used for office training. The
5. "Try to fuse the target while looking
through the two apertures. If singleness goal s for the patient to achieve good performance
cannot be achieved, look at the upright on as many cards as s reasonably possible. The
pointer stick that is stuck on the hole at goal criterion is established by the doctor who
determines t on the basis of professional judg-
position B on the rule. Looking farther
ment. Usually, card 7 (17.5 A ) s the limit for
away from the target causes the eyes to
diverge n relation to the nearer target." patients with convergence excess.
6. "If you are having trouble with seeing the
target as single and clear, these plus-
lenses should help you to attain fusin. If ORTHOPIC FUSIN (T13.15)
you are still having difficulty, these BO
prisms will also help you to appreciate
Purposes
fusin of the target." The purposes of orthopic fusin are to bu i Id fusiona!
7. "After you can fuse with card 1, flip the divergence, to monitor suppression, and to develop
page to card 2 and use the same strategy stereopsis.
to attain clear and single fusin."
8. "Proceed to card 3 and move the double Equipment
aperture slider to position 3 on the rule. The equipment used for orthopic fusin training
Keep the target card at position O [which is ncludes the Keystone Eccentric Circles, Lifesaver
40 cm from the patient's eyes] and main- Card, or similarly designed targets on transparent
tain this fixed distance for subsequent actate cards (see Figure 13-18).
cards. Try to see the fused target clearly
and singly and monitor suppression (e.g.,
dot and plus sign seen simultaneously)." Recommended Office Vision
9. "Notice stereopsis (depth perception) by Training Instructions
seeing one of the circles floating at a dif- For orthopic fusin (not to be confused with
ferent distance from the other circle." orthoptic), no septum s used. This fusin s veiy
10. "Continu to use the help of the pointer, difficult for the eso patient to achieve. It ordinarily
lenses, and prisms, f necessary, and pro- must be preceded by septum devices and by other.
ceed to card 4." less demanding tasks before the patient can per-
11. "Move the aperture slider to position 4 on form it successfully. Hold the two Keystone Eccen-
the rule and repeat the training as tric Circles (use transparent actate cards) at 40 cm
described earlier." from your patient. The patient s instructed to look
12. "The goal s to get to card 7, with the aper through the actate at an object farther away to
ture slider at position 7, for divergence prevent overconvergence and to promote diver-
Chapter17 495
your forefinger pointed upward with the tip being frequent training at home for mximum results. For
level and in Une with the object. Looking at the example, the patient may be advised to practice
object, move the finger slightly to the left or right orthopic fusin for 5 minutes at a time, six times
and try to see two fingers; carefully adjust the fin- daily, for a total of 30 minutes per day.
gers so that one is seen on each side of the object,
equally spaced and level. Seeing two fingers under
these viewing conditions is normal; this is physio- REMY SEPARATOR (T13.14)
logic diplopia."
b. "tyou consistently see only one finger, cover Purposes
one eye, then the other, without moving your head The purposes of the Remy Separator are to build
or extended finger. This demonstrates that the right fusiona! divergence at near, to monitor suppression
eye sees the finger to the left and the left eye sees with divergence demands, and to monitor eso fixa-
the finger to the right. If you still see only one fin tion disparity.
ger, try to think about making the missing one
appear, thus "turning on" both eyes mentally. If this Equipment
is not accomplished, substitute a penlight for the
Equipment for the Remy Separator ncludes Key-
finger to break down suppression." Some patients
stone Colored Cirels (Lifesavers, both opaque and
suppress one eye so intensely that the penlight
transparent) and a manila file folder (see Figures
must be pointed directly at the eyes befo re two
13-16 and 13-17).
lights are seen.
c. "When two fingers (or lights) are seen, slowly
move the finger toward your nose, keeping the Recommended Office Vision
eyes fixed on the distant object. Keep the finger Training Instructions
level with it and the two fingers equally spaced on There are various devices available employing the
either side. This s called framing. If one finger dis- principie of the Remy Separator. One such setup is
appears at any time, stop moving the hand closer the use of a manila folder for a septum and the Life-
to you; do not look away from the distant object savers as targets for orthopic fusin (see Figure
but concntrate and think about the rea to the 13-17). This Bl demand is difficult, even for an ortho-
side where the disappearing finger was; try to phoric individual, and even much more so for an
make it reappear. As soon as you see two, continu esophoric patient. (Use the decimeter rule for calcu-
moving the finger closer to you until it touches lating vergence demand; divide the target separation
your nose. Then extend the arm slowly, to arm's by the decimeter viewing distance.) This s the main
length, seeing two fingers, level, equally spaced, reason for introducing this difficult technique toward
on either side of the object; stop when one finger the end of the training sequence rather than at the
disappears and try to see it again through mental beginning. It is wise to use the transparent card
effort. Practice this until a finger never disappears. before attempting the Lifesavers on an opaque card.
If you had to use a light, repeat using your finger. The patient can look through the transparent card at
Now that you can make one finger appear as two a distant object to get the eyes into a diverging pos-
images, place another finger beside the other and ture. Plus-addition lenses are also helpful to teach
try to see four images. The next step s merely to the patient to fuse with clearness.
move your fingers closer together or farther apart Recommended oral instructions follow:
so that three fingers are perceived, the middle one
1. "Please look through the transparent Lifesaver
being the fused image. Your goal is to be able to do
card and view an object across the room."
this technique quickly and accurately to the mxi
2. "I will put this folder between your eyes
mum Bl range recommended by your doctor."
and place the Lifesaver card on the other
end so that only your right eye can see the
Home Vision Training circles on the right-hand side of the card
Instructions and only your left eye can see those on the
The home visin training instructions are essen- left-hand side of the card."
tially the same as those for office visin training. 3. "While you are looking far away through
The goals are the same, but emphasis is placed on the card, try to imagine a pair of circles
Chapter17 497
Equipment
An ordinary pointer stick or a penlight target can
be used. Lose prisms are introduced in the Bl
orientation. FIGURE 17-6Pencil push-aways. a. The target is moved from the
nearpoint of convergence to a farther distance while maintaining
fusin, b. The same push-away technique using base-in demand
Recommended Office Vision prisms.
Training Instructions
Have your patient bifixate a target (e.g., pencil
tip, at his or her nearpoint of convergence) while Now add an additional 10 A with the prism over
moving the target farther away (Figure 17-6a). the right eye and repeat the aforementioned tech-
Introduce a 10A Bl prism before his or her left eye. nique (see Figure 1 7-6b).
Be sure your patient can fuse the target. Now Recommended oral nstructions follow:
slowly move the target farther away. Measure 1. "Please look at the penlight I am holding
how far your patient could push away or walk and try to keep t single as I move t to your
away from the target and still maintain fusi n. nearpoint of convergence."
498 Chapter17
targets (see Figure 13-5). Then, have your patient The Root Rings target s mounted on a wall at a
look from the top pair to the bottom pair and try to distance of approximately 10 ft (3 m). The rings
achieve singleness and clearness with each fixation are red and green and displaced for lateral dis-
change. Continu with bifixation on each pair of parity to give the binocular stereopsis effect. The
targets on the stereogram. patient wears red-green filters in spectacle form.
Recorrmended oral instructions follow: Another example of a ringlike target for periph-
eral fusin training s the Bernell 500-Sries
1. "I want you to look into the nstrument and Variable Tranaglyph (see Figure 13-10).
try to get the two pictures together. Try to
see the fused image clearly."
2. "Next, I am going to make it more difficult Recommended Office Vision
for you to get the pictures together, because Training Instructions
this time the targets will be more widely
Establishment of sensory fusin s particularly
separated. Try to fuse the pictures and see
important n cases of constant esotropa at far.
clearly."
Using a target, such as Roots Rings, the patient s
3. "With the stereograms that allow for stere
nstructed to wear the red-green spectacles and
opsis, please report the depth effects."
view the target from across the room.
4. "The goal for you is to be able to see the
Recommended oral instructions follow:
targets singly, clearly, with depth, and with-
out any of the suppression clues missing. 1. "Please put on these special red and
Also, you should be able to change from green spectacles."
the top to the bottom targets and back to 2. "Look at the ring target on the wall. Try to
the top targets quickly and easily." see both the red and green rings."
3. "If either the red or green ring disappears,
Home Vision Training let me know. If one of the colors disap
Instructions pears, blink the eye that should see that
color. The right eye with the red filter
The same instructions used in office training apply
should be able to see the red ring and the
for home training, except that the large office mod-
eye with the green filter should see the
els of Brewster Stereoscopes are not practical for
green ring." Note that f Tranaglyphs are
home use. Small hand-held models are used for
used, the right eye with the red filter sees
home training.
the green ring, and the left eye with the
green filter sees the red ring. This s oppo-
site to the Root Rings, because the Trana
PERIPHERAL FUSIN glyph has the colored rings on a light
RINGS (T13.7) background, whereas the background of
Purposes the Root Rings s dark.
4. "When both colored sets of rings can be
Development of sensory fusin at far n true space
seen at the same time, concntrate on the
is the first goal of the peripheral fusin ring training
central portion of the target. The rings
technique. The second goal is to train motor fusin
should be seen peripherally (i.e., out of
at far with Bl prism demands. The third goal s to
the crner of your eye). As you concn
train perception of stereopsis atfar and, eventually,
trate on the central rea, try to keep see-
to maintam the depth effect with increasing prism
ing the rings so that the red and green
demands.
fuse to make a muddy composite."
5. "With practice and allowing time (per-
Equipment haps several days), you will begin to
Large ringlike targets are used n the peripheral appreciate the floating effect of the rings.
fusin ring training. An example is the Root This may occur within the first office
Rings target (see Figure 13-9). Various modifica- training session or perhaps after several.
tions can be custom-made using red and green When this is performed properly, you will
rings on either a black or a white background. notice that the fused ring floats forward as
Chapter17 501
though a rainbow were suspended in the ing technique are basically the same as
room" (Figure 1 7-9). those you learned in office visin training.
6. "Maintain this effect of depth perception 2. Wear the red and green glasses and look at
and slowly move from side to side, observ- the target from approximately half-way
ng the following motion of the floating across the room. Concntrate on the cen
rings. You will notice that the closer image tral portion of the target and be aware of
goes with you; this s the opposite of what the rings of different colors, red and green.
happens in natural viewing of ordinary 3. As you look at the central portion of the tar
objects n everyday seeing." get, try to achieve a depth effect so that the
7. "I am going to put some Bl prisms n front outer rings appear to float n the air and to
of your eyes, and I want you to continu be closer to you than the central portion of
seeing the floating effect as I do this. First, the target.
let's try just a little bit of poweronly 2A 4. When you achieve the floating effect, slowly
before each eyefor a total of 4 A of walk farther away from the target and notice
power." that the floating effect s greater, as though
8. "Now that you can fuse the target and the ring s following you. Have your home
maintain the floating effect with a little bit of helper point to various positions in space
prism, I am going to increase the prism between you and the mounted target. You
power graduaily until you can manage this then tell your helper when he or she gets to
technique with a large amount of demand." the exact position for the ring to be touched.
9. "I will remove the prisms and quickly Your helper cannot see the ring; only you
reinsert them. I want you to recover to see the ring, but you can tell your helper
single visin as quickly as possible when I where to point so that t appears that he or
put them on and take them off." she is actually touching the ring.
10. "I want you to continu doing this with 5. You will notice that the floating ring will
the prisms on and off every few seconds move sideways n the same direction as
and also to vary the technique by occa- your sideways movement. Thus, the ring
sionally looking from far to an object at follows you from side to side as well as
near and then back to the distant ring tar- nearer or farther with your change of dis-
get while recovering fusin each time." tance from the target.
6. Next, perform the foregoing steps in train
ing but with the prisms your doctor has pre-
Home Vision Training
scribed for home training. These will be Bl
Instructions
prisms to forc your eyes to diverge while
1. Your doctor may prescribe one or several you are fusing the floating ring.
types of peripheral fusin rings for your 7. To improve your skills further, try looking
home training. The principies of the train- from the floating ring to an object, such as
502 Chapter 17
Apex Base
FIGURE 17-10The Fresnel membrane prism is thin and is cut to the FIGURE 17-11Flipper prisms, also known as lollipop prisms, for
shape of a spectacle lens. Then ts smooth surface is pressed against rapid modification from base-out to base-in demands. (Courtesy of
the ocular side of the spectacle lens. a. Thickness of a regular specta- Bernell Corp.)
cle prism. b. Fresnel membrane prism on a thin carrier-lens.
times and try to ncrease the power of prism 3. Practice placing a prism n front of one eye,
while being able to fuse with clearness and the thick end toward your nose, and recov-
without suppression. If necessary, repeatthe ering fusin; then remove the prism. Repeat
foregoing with red-green training." this on-off cycle 10 times, rest, and repeat
the cycle another 10 times each day.
Home Vision Training
Instructions
1. Place the televisin trainer on your televisin
screen at home either with the suction cups
or by taping t to the screen. Attempt to fuse
the screen at 40 n. (1 m), as n the office,
through the polarizing filters without any part
of the screen going black, so you don't sup-
press an eye. Be su re the right eye sees the
top target and the left eye sees the bottom.
2. Slowly back away from the televisin screen
until you can maintain fusin at a distance of
at least 10 ft (3 m). Practice slowly moving
closer and farther from the screen for 5 min
utes daily. You may then watch a televisin
show through the filters with the televisin
trainer at the farthest distance comfortable FIGURE 17-13Suppression of an eye as seen by the patient when
for you. using a televisin trainer.
chapter 18 / Vision Training for Exo Deviations
Chapter 14 addresses the techniques listed n this feedback so necessary n this technique and n tech-
chapter and other techniques and therapies for niques that will follow. Another feedback clue to
exo deviations. 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
VOLUNTARY fact, crossing and that there s no suppression.
CONVERGENCE (T14.1) Recommended oral instructions follow:
Purposes 1. "I want you to cross your eyes so that each
The main purpose of voluntary convergence s to eye s pointing toward your nose."
prepare the patient for subsequent convergence 2. "It is all rightfor you to look at something up
training. Another purpose s to develop kinesthetic cise to get started. You can look at the tip of
and proprioceptive awareness of the eye muscles your finger and move it up cise to you."
turning the eyes in a disjunctive, nwardly move- 3. "Try to feel your eyes convergng. This may
ment. This feedback s helpful when doing more be a pulling feeling as your eye muscles
precise exercises later in the course of visin train- strain to cross your eyes."
ing i n exo cases, particularly f there s exotropia. 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
Equipment mous, uncrossed, diplopia as visual feedback
No equipment is required ultimately. In the initial when the eyes are voluntarily crossed.)
phase of voluntary convergence training, use of a 5. "When you think your eyes are crossed, let
real object, such as the tip of a pencil, may be nec- me look at them and give you feedback. I
essary for the patient to bifixate. Later, an imagi- will tell you whether your eyes are actually
nary target, such as an imagined bug flying near crossed."
the nose, may suffice. Eventual ly, absence of a tar- 6. "When I confirm for you that the eyes are
get is the goal. crossed, try to notice the double visin at
far. The double visin lets me know that
Recommended Office Vision you are not suppressing an eye when I see
Training Instructions that your eyes are actually crossed."
7. "If you cannot cross your eyes voluntarily,
Ask the patient to try to cross his or her eyes with-
out looking at a near target. If this proves too diffi- it is all right to use your fingertip or a pencil
cult, have the patient fixate a target at arm's length. tip or similar targets. Try to use an imagi-
nary target next. This might be an imagined
Crossing of the eyes may be difficult in cases of
exotropia of long duration. It may be necessary to bug flying cise to the bridge of your nose."
rely solely on accommodatve convergence to ini- 8. "It may be helpful if you cross your eyes n
tiate convergence. This can be accomplished by a downward gaze, whether you have to use
having the patient look at a nearby target while a real object, an maginary target, or do it
completely voluntarily without the aid of a
viewing t through minus-lens additions, for exam-
ple, a -3.00-D add over both eyes. Addition lenses target. Your goal is to accomplish this task
may be needed n constant exotropia but usually completely voluntarily."
are not necessary in cases of intermittent exotropia 9. "Eventually, you should be able to cross
your eyes voluntarily in down-gaze, then
and, especially, in exophoria.
When the patient can converge by one means or straight ahead and, finally, in up-gaze."
another, have the patient slowly move the target,
such as a pencil tip, toward the bridge of the nose
Home Vision Training
while steadily fixating the target. When this can be
accomplished to within a distance of 10-15 cm
Instructions
from the bridge of the nose, ask the patient to 1. Try to make your eyes cross. Start by look
remove the target and attempt to keep the eyes pos- ing at your fingertip when it is held in front
tured n the converged state for several seconds. At of you near the bridge of your nose.
this time, the patient should be aware of the pulling 2. Ask your helper at home to give you feed
sensation that is the kinesthetic and proprioceptive back about whether your eyes are actually
ChapteMS 507
Purposes
The main purpose of pencil push-ups s to increase
gross (absolute) convergence. Fusional (relative) con-
508 Chapter18
of target) are al I effective ways of breaking suppres- ciency. Suppression can be monitored as training
sion. If the patient contines to have difficulty break- proceeds n building good jump vergence skills.
ing suppression, the pencil push-up technique
should be temporarily abandoned and other antisup-
pression techniques (e.g., stereoscopes, Brock string
Equipment
and beads, red-green filters with penlight, and Vecto- The Brock string consists of a long white cord on
grams [vectos]) should be introduced. which are three differently colored beads (see Fig-
ure 12-7). One end of the string is held against the
tip of the patient's nose, and the other end can be
Home Vision Training held by the doctor or therapist.
Instructions
1. Hold the pencil straight ahead of you as far Recommended Office Vision
out as you can reach. Training Instructions
2. Look at the top letter on the pencil and try
Brock string and beads s analogous to the three-dot
to keep t clear.
card technique (T14.6), which s discussed later,
3. Move the pencil slowly toward your nose
the differences being that there s no septum
and notice whether the letter on the pencil
involved with the Brock string and the fixation dis-
becomes blurry.
tance s farther, being intermedate. Recommended
4. Keep moving the pencil closer and notice
oral instructons follow:
whether t appears to be double.
5. If t is double, tr y to cross your eyes to 1. "Please place one end of the string on the
make t appear single again. tip of your nose."
6. If necessary, trombone the pencil away to 2. "Place the nearest bead approxmately 10
see t as a single target. in. (25 cm) away, the mddle bead
7. Do this several times to determine whether approximately 20 n. away, and the far-
your performance improves. That is, try to thest bead approximately 30 n. away.
move the pencil closer while keeping it clear (These distances will be varied later in
and single. At this tima, a reasonable goal for therapy according to your doctor's recom-
the near breakpoint (doubling) is approxi- mendations.)"
mately 3 in. (8 cm) from the bridge of your 3. "Look at the middle bead and try to
nose. observe that there are images of two
8. Practice the push-up and push-away exercise strings in front of the middle bead and
just as you did in the office training session. that the nearest bead appears to be dou-
9. Do this five times in each series, for a total of bled."
30 minutes per day, and try to maintain good 4. "Also notice that behind the middle bead, at
performance with each push-up and push- which you are looking, you can see two
away. strings, and the farthest bead appears to be
10. An ultmate goal for you is to perform this doubled."
exercise easily and accurately so that you can 5. "Notice that the doubled string appears to
trombone the pencil from arm's length to make an X pattern, and the string images
approximately 2 in. (5 cm) from the bridge of cross at the middle bead."
your nose and trombone it back to arm's 6. "Put on these red-green spectacles, with the
length. red lens over your right eye and the green
lens over your left eye. Look at the middle
bead as you did before. Do you notice that
BROCK STRING AND one string appears to be red and the other
BEADS (T14.5,T13.6) green? Observe that in front of the middle
bead, the red portion of the string is on your
Purposes left side and the green portion is on your
The first purpose of the Brock string and beads tech- right side."
nique is to increase absolute (gross) convergence. 7. "Continu look ing at the m iddle bead
Relative (fusional) convergence can also be ncreased and observe that beyond the middle
n many cases, particularly in convergence insuffi- bead, the red portion of the string s on
510 Chapter18
Intersection of string
image behind the beads
your right side and the green portion is may be changed later in therapy accord-
on your left side." ing to your doctor's recommendations.)
8. "If fixation is naccurate and beyond the 3. As you look at the middle bead, you
middle bead, the strings will appear to can be aware of two strings farther away
cross behind the double-image bead at and that the farthest bead appears to be
which you are supposed to be looking." doubled.
(Figure 18-3 Ilstrales string images inter- 4. As you look at the middle bead, you can be
secting beyond the middle bead.) aware of two strings closer to you and that
9. "Cross your eyes so that the strings cross the nearest bead appears to be doubled.
exactly on the bead at which you are 5. Keep looking at the middle bead and
looking." notice that the doubled string appears to
10. "Look at the farthest bead and notice the make an X pattern and the strings should
colored strings crossing at that point." cross exactly on the middle bead.
11. "Jump to the closest bead and notice the 6. Put on the red-green spectacles with the red
colored strings crossing at that bead." lens over your right eye and the green lens
12. "Remove the red-green spectacles and over your left eye. Look at the middle bead
repeat the preceding exercises as you as before. Notice that one string appears to
have been doing." be red and the other green. Look at the mid
13."Try to become proficient n jumping dle bead and see that the red part of the
from one bead to the other while seeing near string is on your left side and the green
the strings cross at the bead and notic- part is on your right side.
ing that the other two beads are dou- 7. Continu looking at the middle bead and
bled." observe that beyond the middle bead,
14. "I am going to put special lenses and prisms the red portion of the strings is on your
on your eyes as you perform this technique right side and the green portion is on
that you have learned." your left side.
8. Look at the farthest bead and notice the col
ored strings crossing exactly on that bead.
Home Vision Training 9. Cross your eyes to jump to the closest
Instructions bead and try to see the colored strings
1. Place one end of the string on the tip of crossing exactly on that bead.
your nose, just as you did n office training. 10. Take off the red-green glasses and keep
2. Place the nearest bead approximately 10 performing the exercises as you have been
in. away, the middle bead approximately doing.
20 in. away, and the farthest bead at 11. Try to be quick when jumping from one
approximately 30 n. (These distances bead to the other and be su re that you see
Chapter18 511
the strings cross exactly on the bead; notice that When your patient s able to achieve fusin of
the other two beads are doubled. 12. Wear any the largest dots, he or she is asked to report how
special lenses and prisms that were many other dots are seen. Your patient should be
prescribed for this exercise. These lenses able to see two middle-sized dots and two of the
and prisms may be changed as you smallest dots, if there s no suppression. If the per-
progress in visin therapy. Do this training ception of physiologic diplopia is not achieved
technique each day as your doctor because of either suppression or perceptual
prescribes. unawareness, cover an eye on the side of the col-
ored dots seen. For example, if only red dots are
seen (and the red dots are on the patient's right
side), cover the right eye so that only the blue dots
THREE-DOT CARD (T14.6)
are visible. Then, uncover the eye and urge the
Purposes patient to be aware of both the red and blue dots
The purposes of this training technique include the simultaneously.
following: (1) mercase gross (absolute) conver- Next, your patient should attempt to fuse the
gence; (2) ncrease fusional (relative) convergence; middle dots. He or she should diplopically see
(3) improve sensory fusin by monitoring suppres- two larger and two smaller dots. Homonymous
sion during motor fusin stress; and (4) build good (uncrossed) diplopia should be perceived for the
jump vergence skills. largest dots, whereas heteronymous (crossed)
diplopia should be perceived for the smallest
dots. Your patient should next attempt to fuse the
Equipment smallest dots; the other dots should appear dou-
The three-dot card (Allbee or similarly made cards) is bled. If your patient is capable of fusing each of
a 2.5 x 5.5-in. cardboard target on which appear the three pairs of dots, he or she should practice
three red dots on one side and three blue dots on the jump vergences by rapidly shifting fusin from
other side. The dots are arranged n gradually increas- the largest dots to the middle dots, then from the
ing size on each side of the card. The edge of the middle dots to the smallest dots. When fusing
card, nearest the smallest red dot and smallest blue each set of dots, your patient should see the other
dot, is held vertically against the tip of the patient's two sets diplopically.
nose. The card acts as a septum (see Figure 14-1). A modification can be made to increase the dif-
ficulty of this technique, thus contributing to
Recommended Office Vision improvement of fusional convergence. The patient
Training Instructions should wear base-out (BO) prisms (e.g., Fresnel,
lose hand-held, or flipper prisms) while perform-
Have your patient hold the card on the tip of his or
ing the task.
her nose as just described and instruct the patient
Recommended oral instructions follow:
to look at the largest dots (red and blue) and to try
to make them fuse into a purple dot image. The 1. "Please hold this small card, with colored
fusin of a red and blue dot should appear to be dots on t, placed on the tip of your nose."
purple. If this fusin of colored dots cannot be 2. "Be sure that the end with the smallest dots
accomplished, there are two modifications to the is closer to you and that the red dots are on
technique that may help. One method is to remove your right side and the blue dots are on
the septum effectively, which s accomplished by your left side."
using a three-dot card from which the top portion 3. "Try to cross your eyes, just like you know
has been cut off down to the top of the dots. Your how to do by looking at a pend tip cise
patient can then look directly at the dots without to you, and try to fuse the largest red dot
dissociation caused by the septum (see Figure with the largest blue dot so that the red and
14-2). Another modification of the three-dot card blue colors blend into a purplish color."
technique can help your patient fuse the farthest 4. "When you get the large dots fused, you
dots; this modification consists of having the will notice that the middle-sized and the
patient move the card slowly away from the tip of smallest dots appear to be doubled. This
the nose to approximately 1-2 in. and then attempt perception is normal and indicates that you
to fuse the farthest (largest) dots. are not suppressing an eye."
512 Chapter18
5. "Next try to fuse the middle-sized dots. nose. This farther distance from your eyes
When you have achieved this, you should to the card may help you fuse the dots.
notice that the other pairs of dots appear to When the large dots are fused, check to be
be doubled. Again, this perception is nor sure that you are seeing two sets of the mid-
mal." dle and small dots. If you can easily fuse
6. "Now try to fuse the nearest (the smallest) the large dots, work on fusing the middle
pair of dots. Notice that the other pairs of dots, then the smallest dots.
dots appear to be doubled." 7. Practice jumping from fusing the large dots
7. "Finally, try to jump from one pair of dots to to the middle dots to the small dots for 5
another in quick succession and with ease." minutes. Be aware of the other dots as dou
bled when fusing each set of dots. At least
Home Vision Training 20 cycles from large to small dots should
be attempted in each trial. A score of 20
Instructions
cycles means that you alternated looking at
1. Hold the card on your nose and try to cross different dots a total of 40 times in each
your eyes so that you see the large dots as exercise trial. Repeat the exercise trial for a
one purplish colored dot. How many mid- total of 30 minutes per day.
dle dots do you see? Notice on which side 8. Practice jumping from dot to dot as you were
the middle red dot is located. trained to do in the office. Your eyes should
2. Now try to cross your eyes a little more, so jump willfully. Repeat the sequences as pre-
that the middle dots come together to make scribed. Check to be sure that you are seeing
one purplish dot. How many small dots do the other sets of dots as doubled when fusing
you see? Notice on which side the small the one pair of dots of your choice.
red dot is located. How many large dots do
you see? Notice on which side the large red
dot is located.
3. Try to cross your eyes even more so that the APERTURE-RULE TRAINER,
smallest dots come together to form one SINGLE APERTURE (T14.12)
purplish dot. How many middle dots do Purposes
you see? Notice on which side the middle
The main purpose of using the Aperture-Rule Trainer
red dot is located.
is to improve fusional convergence, particularly n
4. Now try to fuse (make into a single dot) the
cases of convergence insufficiency. Other purposes
large pair of dots; then jump to the middle
include improving the range and speed of fusional
pair of dots and fuse them; then jump to the
convergence, which is BO training, as well as moni-
small dots and fuse them. Notice that while
toring suppression with ncreasing fusional demands.
you were jumping from dot to dot, you
Suppression and fixation disparity can also be moni-
were able to see the other sets of dots as
tored during fusional vergence demands.
doubled.
5. Try, by looking at an object across the room
and jumping to near, to fuse dots on the Equipment
card. First, look at an object across the The parts of the nstrument are a "ruler" base, a
room for a count of 3 seconds and then single-window aperture, a double-window aper-
look at near to fuse the large dots on the ture, and a spiral-bound set of picture cards (see
card. Look back to the object across the Figures 13-14, 14-3, and 17-3). To assemble the
room for a count of 3 and then jump to fuse Aperture-Rule Trainer for convergence training,
the middle dots on the card. Finally, look unfold the "arms" of the ruler base so that they are
back at the object for 3 seconds and then straight. For initial suppression checking and align-
try to fuse the smallest dots. ment of the patient in the instrument, use the dou-
6. Practice the far-near-far vergence exercise ble aperture and the first two targets. (Refer to the
for 5 minutes each day. If necessary, use the section on use of this nstrument for eso deviations
cut card (top of card cut off) and, also if n Chapter 17.) Slide the single-window aperture
necessary, hold the card away from your 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 suppres-
sion 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 pic- minus lenses or base-in (Bl) prism to help your
ture cards onto the base n the O position. patient fuse with clear binocular visin.
Place the AP1 Card at O on the rule with the When your patient can fuse a particular set of
single aperture mask at setting / and 2. Training targets, you should monitor for target clarity. Addi-
can now begin for fusional convergence (BO tional minus lenses may help if the patient has dif-
demands) n cases of exo deviation. ficulty clearing the fused target. Suppression can
be monitored by control marks that are seen by
Recommended Office Vision one eye or the other. Stereopsis can be monitored
Training Instructions by, for example, the targets that have eccentric cir-
cles; ask the patient which circle floats toward him
Adjust the Aperture-Rule Trainer so that the end of
or her. See examples of targets in Figure 18-4.
the base with the single aperture s toward your
The target demand of a particular card s calcu-
patient and at the level of his or her nose. Select the
lated by the formula: vergence demand = (card num-
API Card to start, assuming the first two suppression
ber) x 2.5. For example, card 2 has a demand of 5A.
and alignment cards, using the double aperture,
Continu with higher-numbered cards until your
have been presented. Instruct your patient to try to
patient can no longer perform the task. Follow
fuse the targets on the picture card into one image
instructions on the picture card as to where the
by converging his or her eyes. Your patient is
aperture should be placed for each card.
nstructed to point his or her eyes to the single-aper-
Lenses can be used to enhance the difficulty of
ture window. If your patient initially has difficulty,
this technique so as to train fusional convergence.
you should remind him or her of what convergence
Plus lenses crate more demand on fusional conver-
feels like. This kinesthetic perception should be
gence. Prisms might also be used to make this tech-
familiar, from experience of previous techniques n
nique more difficult, as BO prisms crate more
therapy that were relatively easy (e.g., pencil push-
demand on fusional convergence. Recommended
ups). If there is difficulty positioning the eyes, you
oral instructions follow:
should place a pointer or pencil tip n the desig-
nated hole just behind the aperture. This s the same 1. "The goal of this activity is for you to learn
for the AP2 card. For al I other cards (3-12), place to cross your eyes, accurately and quickly."
the pointer tip at the plae of the aperture and direct 2. "Position yourself so that the end of the rule
your patient's attention to the pointer, which can be s on the tip of your nose." (Position the
at the top of the window. You can also try adding nstrument appropriately for the patient.)
514 Chapter18
3. "Try to make the two pictures nto one. I train sliding fusional convergence (BO demands) in
will help you by having you look at the cases of exo deviations and sliding fusional diver-
pointer placed at the window." gence (Bl demands) in cases of eso deviations.
4. "Try to keep the fixed mage clear. I will Other purposes are to monitor for suppression dur-
help you clear the image by using lenses ing ncreased prism demands, to develop second-
before your eyes." degree and third-degree fusin skills, and to train
5. "We will start with easy targets and proceed step vergences.
to more difficult targets as you progress n
visin therapy." Equipment
6. "An advanced technique is jump vergences, The patient views the targets (either vectos or
for which you alternately look away at a dis- Tranaglyphs) that are mounted on the Dual Pola-
tant object and then down at the picture chrome Illuminated Trainer while wearing crossed
card. The objective here s to make brisk, polarizing viewers. Selected vectos are Usted here
accurate changes n fusiona! vergence for n appropriate order of difficulty (and are shown in
clearness and singleness." Figure 13-10):
7. "Another advanced technique s to use the
BO plus-BI minus (BOP/BIM) principie. BO 1. Quoits (two-piece) (see Figure 13-11 a)
prisms and plus lenses act n the same way in 2. Clown (two-piece) (see Figure 13-11 c)
that they crate a convergence demand, 3. Mother Goose (two-piece) (see Figure
whereas Bl prisms and minus lenses crate a 13-1 le)
divergence demand. For example, you should 4. Spirangle (two-piece) (see Figure 13-11 b)
try to maintain fusin of the picture while 5. Figure 8 (one-piece) (see Figure 13-11f)
using the special plus-minus flippers. Start 6. Chicago Skyline (two-piece) (see Figure
with a lower power (e.g v1.00) and work 13-11d)
your way up to higher powers. The objective
If Tranaglyphs are used n the Dual Polachrome
here s to obtain brisk, accurate changes in
Illuminated Trainer (see Figure 13-11), the patient
relative vergence and accommodation."
should wear the appropriate red-green filters.
BO training is emphasized in cases of exo devi-
Home Vision Training ation. Vectograms and Tranaglyphs are viewed at
Instructions near, but they can be projected onto a distant
1. Practice making the pictures on each card screen for training at far. Note that a special
single and clear as quickly as you can. screen is necessary for vectographic projection.
Once you get the picture single and clear, Small targets (Minivectograms and Minitrana-
try to maintain t steadily for 10 seconds. glyphs) are also available for office visin training
2. For each picture, be sure that you see it and are particularly applicable for home visin
clearly, so that nothing disappears (e.g., the training (Figure 18-5; see also Figure 16-6). These
plus sign or the dot) and try to see one of small training devices are, however, for near
the circles floating toward you. viewing only.
3. Your goal is to repeat the technique success- The immediate discussion here focuses on
fully on higher-numbered cards, eventually T14.9, convergence training at near.
up to card 12. It is good to have a specific
card number as an intermedate goal, based Recommended Office Vision
on your performance in office training. Training Instructions
Place a chosen vecto pair (e.g., starting with a pair
VECTOGRAMS AND of Quoits sudes) nto the slots of the Dual Pola-
TRANAGLYPHS: CONVERGENCE chrome Illuminated Trainer. Superimpose them for
TRAINING AT NEAR (T14.9) a zero prismatic demand. Place the target directly
in front of your patient so that the vecto is at a
Purposes viewing distance of 40 cm. Have your patient wear
The Dual Polachrome IlluminatedTrainer is applica- crossed-polarizing filters. Demnstrate what sup-
ble for either vectos or Tranaglyphs. It is used to pression looks like by alternately covering the eyes
Chapter18 515
and asking your patient to report what image or Portion of the picture seen as three-dimen-
mages disappear. Ask your patient to report sup- sional, which indicates stereopsis.
pression if t ever occurs during the activity. The Any effect of the whole picture appearing to
patient should accurately report the appropriate float either toward or away as the vergence
monitor if the left eye suppresses, which, for exam- demand is increased, either BO or Bl (small-
ple, is the L. If the right eye suppresses, the R in/large-out [SILO] effect, meaning the image
should appear to be missing. appears to be smaller and moving n closer to
Instruct the patient to keep the target single and the patient [which may occur with fusional
clear as long as possible by converging the eyes. convergence] or the image appears to be
Remind the patient of what convergence feels Nke larger and moving out farther from the patient
(e.g., eyes feel like they are working, turning [which may occur with fusional divergence]).
toward the nose, looking cise). Ask your patient Whether the picture appears to increase or
to report any proprioceptive feelings (e.g., pulling decrease in size as vergence demands are
sensation). Slowly increase the BO demand, in introduced (SILO effect). If this occurs, explain
cases of exo deviation, by sliding the transparen- SILO to your patient.
cies apart so that numbers can be seen in the win- Mximum blurpoint, breakpoint, and recovery
dow of the mask in the bottom ruler on the target. point.
Each number represents a prism diopter of demand Any suppression, in which eye, the frequency,
A
on vergence. This ratio applies only when the and under what conditions (e.g., with 15 BO).
viewing distance is 40 cm. Ask your patient to
report the following occurrences: Recommended oral instructions follow:
516 Chapter18
1. "The goal of this technique is for you to you cise the other eye? Notice whether any
learn to turn your eyes nwardly, crossing of these images disappear at any time during
them efficiently as a team." this training activity.
2. "Put on these special glasses." (These are 4. Your job is to keep the target single and clear.
crossed-polarizing lenses if using vectos or You will need to turn your eyes inward as f
red-green-filtered spectacles if using Trana- looking at your nose. Please begin to pul the
glyphs.) target slides apart and maintain fusin (single
3. "Direct your attention to the target, espe- ness) until diplopia (doubleness) is reported.
cially suppression checks. What happens Record the break (doubling) vales (number
when I cover this eye? And when I cover ing on the masked rule at the bottom of the
the other eye? Let me know whether any of target). Also report any changes n target size.
these images disappears at any time during Does t seem to be moving closer to you or
this training activity." away from you? Is it getting smaller, larger, or
4. "Your job is to keep the target single and staying the same size?
clear. You will need to turn your eyes inward 5. Note the eye that you suppressed, what
as if looking at your nose. Please begin to caused suppression to occur, and how you
pul the vectos (target sudes) apart and main- were able to break the suppression. After you
tain fusin (singleness) until diplopia (dou- perceive doubleness, try to make the picture
bleness) is reported. Record the break into one again by turning your eyes inward.
(doubling) valu from the numbering on the Record the number vales of your blurpoint,
masked rule at the bottom of the target." doubleness, and recovery to singleness and
5. "Report any changes perceived n the tar whether or not SILO (target size or distance
get. Tell me whether the target changes in changes) was appreciated. Also, describe any
any way. Does it seem to be moving closer suppression that may have occurred.
to you or away from you? Is t getting
Note for the patient that techniques using Mini-
smaller, larger, or staying the same size?"
vectograms and Minitranaglyphs are similar n prin-
6. "If you notice any suppression, break it by
cipie to those that use the Dual Polachrome
blinking. Note the eye that s suppressing and
Illuminated Trainer. The apparatus for a Minivecto-
how you were able to break the suppression."
gram, for example, consists of two clear targets with
7. "Report diplopia and make the picture into
suppression checks, a plstic holder n which the
one again by turning your eyes inward."
targets can slide, mutual exclusin viewers (crossed
8. "Please record blurpoint, breakpoint, recov-
polarizing filters), and a translucent piece of plstic
ery vales, whether target size or nearness
that fits inside the holder but behind the Minivecto-
(SILO) was appreciated, and describe any
gram. Recommended oral instructions follow:
suppression that occurred."
1. "The goal of this technique with Minivecto
Home Vision Training grams and Minitranaglyphs is for you to learn
Instructions to turn your eyes inward efficiently as a team."
2. "Put on the special glasses."
Ordinarily, the Dual Polachrome llluminatedTrainer is
3. "Look for the suppression checks."
nottaken home, but sometimes exceptions are made.
4. "Your job is to try to keep the target single
Otherwise, Minivectograms and Minitranaglyphs will
and clear while you pul this card with the
be lent to patients for home visin training.
L on t to the right. You will need to turn
1. The goal of this training technique s for your eyes inward as f looking up cise at
you to learn to turn your eyes inward, your nose. Notice whether the target
crossing them efficiently as a team. changes n any way. Does t seem to be
2. Puton these special glasses. (These are crossed- moving closer to you or away from you? Is
polarizing lenses if using vectos or red-green- t getting bigger or smaller? Is the larger cir-
filtered spectacles f usingTranaglyphs.) cle or the smaller circle closer to you?"
3. Direct your attention to the target, especially 5. "If you notice suppression at any time, try
the suppression checks. What happens when to break the suppression by blinking. Note
you cise an eye? What happens if instead the eye that suppressed, the conditions that
Chapter18 517
Right eye
VECTOGRAMS AND
TRANAGLYPHS: CONVERGENCE
FIGURE 18-6Example of convergence walk-aways with vecto-
WALK-AWAYS (T14.10) graphic 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.
Purposes
The main purpose of convergence walk-aways is to
promote fusional vergence at increasing fixation dis- 1. "I want you to wear the special glasses and
tances. If the patient fuses well at near but has diffi- look at the targets at this near distance of
culty at far, this technique helps build confidence for 16 n. (40 cm)."
the patient when trying to meet vergence demands at 2. "Try to fuse them while I slide the targets
far. The farther distance makes the image smaller and apart to number 12. This represents 12
more effort s required to keep from suppressing these prism diopters of vergence demand."
smaller images. Also, stereopsis is more difficult as 3. "When you can keep them fused so that the
image is clear and single, slowly walk away
the fixation distance increases; this technique sharp-
to twice the distance, 80 cm now, and main-
ens stereopsis.
tain fusin with clear and single visin."
4. "When you can keep the targets fused at
Equipment this farther distance, slowly walk away
Convergence walk-aways are performed with the even farther to twice the distance, 160 cm
same equipment as was described for Recom - now, and maintain fusin with clear and
mended Office Vision Training Instructions (Vecto- single visin." (This technique sets the stage
grams and Tranaglyphs [T14.9]). The difference n for the next technique, projected BO slides
the therapeutic training technique s that the [see 113.10,714.11].)
fusional vergence demand becomes mathematically 5. "Your next training technique will be at a
less as fixation distance increases. For example, far distance in which the targets will be
A
suppose there s a 12 BO demand at the conven- separated so that you can learn to cross
tional 40-cm distance. When the patient moves your eyes even more efficiently."
away from the instrument to 80 cm, the BO demand
A
s reduced to 6 . This mathematic advantage may
Home Vision Training
help the patient who has an exo deviation at far. For
A A
example, 12 demand at 40 cm is only 6 demand
Instructions
at 80 cm (see Figure 18-6 for clarification). 1. Take the slides (either Vectograms or
Recommended oral instructions follow: Tranaglyphs) and practice the technique as
Chapter18 519
a BO direction so you will have to converge. line may be missing so that you see only a
This technique of training builds a large ver- horizontal line.
gence range for you at a far distance." 9. Seprate the targets slowly until you can no
longer keep the fused image clear and single.
Just before that point is reached, stop moving
Home Vision the pictures apart and continu fus-ing with
Training Instructions clearness and singleness. 10. Once you have
Note to patients: This technique may not be appli- completed the previous steps satisfactorily,
cable if you do not have access to an overhead slide the targets into a Bl direction so you will
projector. If one s available and if your doctor has have to diverge your eyes to fuse. Letters will
lent you the special screen, you can practice the show through the little window when there is a
projected BO technique as you were trained to do divergence demand. Slide the targets back
in the office. The following routine is suggested, into the BO direction so you will again have
but this may have to be conducted in the office as to converge your eyes. This training
equipment may not be available at home. technique can help you to build a large
vergence range at a far distance.
1. Put on the magic glasses and look at the
illuminated screen across the room. Note that if an overhead projector is not avail-
2. Use a familiar pair of vectographic slides able, the patient can still perform home training,
that your doctor has prescribed. Place them although neither as conveniently or effectively, by
on the overhead projector. You will notice taping the vectos to a window that is lluminated
that the same pictures are now projected by daylight. This allows the patient to train fusiona!
onto the special screen on the wall. convergence at far in a manner similar to that
3. Try to fuse the pair of targets, just as you applied when using projected vectos.
learned to do at near when you were look-
ing directly at these pictures.
4. Put them together at the zero position; this
is an ortho demand and you don't need to CHIASTOPIC FUSIN
converge your eyes when the targets are in COLOREO CIRCLES (T14.14)
ortho position. When you can fuse the pair Purposes
of slides, put in some BO demand to make
The main purpose of the chiastopic fusin technique
you cross your eyes to maintain fusin.
is to increase fusional convergence. This technique s
Start with 2A. The number 2 should show
also good for monitoring suppression during motor
through the small window of the masked
fusin demands. Because this technique can enhance
ruler. Now you will have to converge your
open-space fusin skills, there is strong transfer from
eyes to see singly.
the visin training to ordinary viewing n life.
5. When you can see singly with this conver-
gence demand, try to see the fused image
clearly. Equipment
6. As your performance with this exercise Any two similar objects or pictures may be used.
mproves, place greater and greater demands For example, two identical coins can be positioned
on yourself to converge your eyes more and on a tabletop with a slight horizontal separation
more. Do this by separating the pictures in the (e.g., 2-3 cm). Two real objects may be a good way
BO direction, so that larger numbers show to start a patient learning to perform chiastopic
through the opening in the masked ruler. fusin. The same principie of cross fusing applies
7. As you make the convergence demand to representations of objects on a printed page,
greater, look to see whether the fused image such as the Keystone Colored Greles, known clini-
starts to blur or breaks into two images. cally as Lifesavers. (Refer to Figures 14-6 and 14-7.
8. Look also for any suppression. You will Also see examples of targets of Bernell for chias-
know that suppression of an eye is occur- topic form n Figure 18-7.) The first discussion that
ring f something s missing that should be follows pertains to the Lifesavers.
seen by that eye. For example, the vertical
520 Chapter18
s
fovea
Cyclopean eye
FIGURE 18-7Examples of eccentric circles for the purpose of chias- If fusin cannot be accomplished, have the
topic fusin. In the upper right crner are barrel convergence cards patient hold a pencil tip between the two Lifesavers.
similar to the three-dot card. (Courtesy of Bernell Corp.)
Ask the patient to move the pencil slowly toward his
or her eyes when concentrating on the tip. Your
patient should be aware of the Lifesavers seen
Recommended Office Vision behind the pencil. At a certain point, the patient
Training Instructions should become aware that there is a doubling effect
to produce a percept of four Lifesavers. Have your
Have your patient attempt to fuse a pair of Lifesav-
patient continu to bifixate the pencil as t moves
ers from a distance of 40 cm by voluntarily over-
closer until the two "inside" Lifesavers fuse; henee,
converging to obtain a percept of three Lifesavers.
three mages should be reported. When fusin s
The middle mage should be in clear focus; t s
stable, have the patient remove the pencil while try-
considered to be the fused image. The suppression
ing to maintain fusin. Recommended oral instruc-
clues are the two laterally displaced, nonfused
tions follow:
mages. (Figure 18-8 Ilstrales the principie of ch-
astopic perception.) The separation distance of 1. "Attempt to fuse the two bottom circles from
common points on the two objects is used to cal- a distance of 40 cm (approximately 16 in.
clate the demand on fusional vergence. The sepa- by voluntarily overconverging to obtain a
ration in millimeters is divided by the fixation percept of three mages."
distance n decimeters. For example, f the targets 2. "If you cannot do this at first, you can look
are 4 cm (40 mm) apart and the fixation distance s at the tip of a pencil, so that your eyes will
40 cm, convert 4 cm to 4 dm. Then calclate using cross n front of the card with the printed
the fraction 40/4 to yield 10 A BO demand on Lifesavers."
fusional convergence. (See the discussion on the
Griffin decimeter rule n Chapter 13.)
Chapter18 521
3. "Move the pencil slowly back and forth you are able to perform this technique with
until you can achieve the perception of the top row of circles on the card.
three Lifesavers n a row." 4. Starting with the bottom row of circles, prac
4. "You can see that the fused central mage s tice looking away from the fused image of the
a combination of red and green colors." circles at a distant object. Now look back at
5. "Try to maintam fusin of the central mage the bottom row of circles and attempt to
and remove the pencil." regain fusin of the circles. Repeat this cycle
6. "When you can mamtain fusin, try to slowly at least 20 times each day.
clear the target. This s accomplished by 5. When this s easily accomplished, attempt
keeping your eyes fully converged while this technique with the next higher rows of
relaxing your focusing." circles (second set upward from the bottom
7. "I will place these special lenses, minus of the card). Continu this pattern until you
power, to help you, and I may also try can perform this technique with the top
prisms, Bl, to help you learn this technique row of circles on the card.
of chiastopic fusin."
8. "You can also try moving the card siowly
closer to you while maintaining enough
CHIASTOPIC FUSIN
convergence to continu fusing sufficiently.
ECCENTRIC CIRCLES (T14.14)
This closer distance may help clear the
blurred, fused image. This would happen if Purposes
you are focusing at a nearer distance than The main purpose of chiastopic fusin with eccen-
the Lifesaver card." tric circles is to ncrease fusional convergence and
9. "Attempt to fuse the next level of circles, sec- monitor suppression during motor fusin stress.
ond set upward from the bottom of the card." This technique is excellent for enhancement of
10. "The next higher level s attempted until open-space fusin skills while developing second-
you are able to fuse the top level of circles and third-degree sensory fusin skills. Training to
on the card." ncrease gross (absolute) convergence can also be
done by having the patient either trombone the tar-
gets or do near-far jump vergences while maintain-
Home Vision Training ing the chiastopically fused mage.
Instructions
1. Practice attempting to fuse the circles for Equipment
5 minutes each day. If necessary, use the
The opaque stock Keystone Eccentric Circles are
pencil tip to help get started. Practice
preferred for chiastopic convergence (BO) training.
accomplishing fusin using the pencil tip, (See Figure 13-18.)
then taking the pencil away while keeping
the central circle fused. Attempt to fuse
the circles without the assistance of the Recommended Office Vision
pencil. Training Instructions
2. Practice moving the card closer toward you
Give the patient instructions similar to those
while maintaining the fusin, depth, and
applied to Lifesaver training. Recommended oral
clarity of the central circle. When you can
instructions follow:
no longer keep the central circle fused and
clear, then move the card away from you 1. "The Eccentric Circle cards should be held
and start again. Repeat this cycle slowly at 40 cm from you and adjacent to each other
least 20 times each day. with the same letters n the bottom crner
3. When this can be easily performed with the side-by-sidefor example, both As next to
bottom set of circles, attempt to practice each other."
this technique with the next higher row of 2. "Attempt to fuse the two circles by volun
circles (second set of circles from the bot tar! ly overconverging to obtain a percept of
tom of the card). Continu this pattern until three objects."
522 Chapter18
3. "Try to see the fused middle target clearly, just 2. Slowly seprate the cards while you strive
as you were able to do with the Lifesaver to maintain fusin, depth, and clarity of the
card." central mage.
4. "Try to appreciate stereopsis; this is the 3. You may notice that the central mage
depth effect of the smaller circle either appears to get smaller as the cards become
floating toward you or away from you n more separated (SILO effect). You may pos-
relation to the larger circle, which stays n sibly see the fused middle mage coming
the same place, or at the same distance, as slightly closer to you n relation to the out-
the card on which it is printed." side pair of targets (SILO effect).
5. "Notice whether the As or Bs are adjacent 4. When you can no longer keep the central
and whether the smaller circle appears to image fused as the card separation becomes
be closer or farther in relation to the larger greater, then move the cards closer together
circle." and repeat the preceding steps.
6. "If fusin cannot be accomplished, hold a 5. Starting with the cards adjacent to one
pencil tip between the two cards of circles. another, practice looking away from the fused
Slowly move the pencil toward you while image to a distant object. Now look back at
concentrating on seeing the tip. You should the circles and attempt to regain fusin.
be aware, by indirect visin, of the targets 6. When this is easily accomplished, attempt
behind the pencil. At a certain point, you this near-far jump vergence training with the
should become aware that the targets are cards slightly separated. Continu this exer-
beginning to double and, eventually, you cise until you can perform this training tech-
should see three targets." nique with the cards more widely separated,
7. "When you can do this, remove the pencil according to your doctor's recommendations.
and try to maintain fusin (middle image)
for at least one-half minute."
8. "Seprate the cards laterally. Do this slowly
so you can maintain fusin of the middle
VERGENCE ROCKTELEVISIN
mage." TRAINER AND PRISMS (T14.16)
9. "Try to notice any size change of the fused Purposes
middle target. Typically, the mage will The main purpose of vergence rock using a televi-
appear to become smaller as the lateral sin trainer and prisms s to monitor suppression
separation of the cards becomes greater." during fusional convergence training. Other impor-
10. "Continu to seprate the cards until blur- tant purposes are to develop a good fusional con-
ring is noticed. Estmate the approximate vergence range and facility at far.
separation distance of the two cards."
11. "Continu to seprate the cards until dou-
bling of the middle image s observed, Equipment
meaning that fusin was lost. Estmate the The televisin trainer (see Figure 12-9) is an ac-
approximate separation distance of the two tate sheet fitted with rubber suction cups that
cards for this breakpoint." allow the sheet to be attached to the screen of a
12. "Move the cards closer together to regain televisin set. On the actate sheet are two large
fusin. Your doctor will prescribe the goals for sections of either red-green (anaglyphic) or
breakpoints and recovery (e.g., 7 in. apart)." crossed-polarizing filters that produce mutual
exclusin of the images seen by each eye when
corresponding filters are worn. BO prisms come
Home Vision Training in various forms, such as Fresnel Press-Ons, lose
Instructions prisms, and flipper prisms. (See Figure 12-9.)
1. "Please put on the crossed-polarizing spec- glasses, just as you learned to do in the
tacles and look at theTV screen from a dis- office.
tance of approximately 40 in. (1 m)." 3. Cise one eye and notice that a certain part
2. "\ will place this special sheet in front of of the TV picture disappears.
the screen, and I want you to watch the TV 4. Open that eye and cise the other eye and
picture through the sheet while you are notice that another portion of the TV screen
wearing the special glasses." disappears.
3. "Purposely cise one eye and notice that 5. Holding both eyes open, try to see all por-
par of the TV picture disappears." tions of the TV screen at any one time.
4. "Open that eye and cise the other eye and 6. Back away to approximately double the
notice that another portion of theTV screen distance from the TV and try to see all of
disappears." the picture all of the time.
5. "With both eyes open, try to see al I por- 7. Move back farther and try to see all of the
tions of the TV screen at one time." picture all of the time, as you learned to do
6. "I want you to back away to about double earlier n the office training.
the distance and try to see al I of the picture 8. Place prisms before your eyes, as pre-
al I of the time." scribed by your doctor, so that your eyes
7. "Now try to back farther away and try to see will be forced to converge in order to see
all of the picture all of the time, as before." the picture singly.
8. "I will place some prisms before your eyes 9. When you can see the TV picture clearly
so that your eyes will be forced to converge and singly, add more prism power (either
n order to see the picture singly." lose or lollipop prisms) to make you con
9. "When you can see the TV picture clearly verge your eyes even more.
and singly, I will add more prism power to 10. Try to see the picture clearly and singly for
make you converge your eyes to an even a training period of 15 minutes while see-
greater extent, while you try to see clearly ing all of the picture most of the timethat
and singly." is, without a portion of the TV picture fad
10. "I want you to be able to see the picture ing or disappearing.
clearly and singly for a training period of 11. Try to regain fusin of the picture each time
15 minutes with hardly any suppression you look through a different prism. Regaining
that s, without a portion of the TV picture fusin should be easy and quick, n approxi
fading or disappearing." mately 3 seconds with each prism. The pic
11. "I want you to regain fusin of the picture ture that s fused after each new prism should
each time I flip a different prism power before be clear and single.
your eyes. Regaining fusin should be easy 12. You will be given prisms of stronger power
and quick, taking approximately 3 seconds as you progress n visin therapy.
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 VERGENCE ROCKBAR
successfully n therapy." READER AND PRISMS (T14.17)
Purposes
The main purpose of vergence rock using a bar
Home Vision Training
reader with prisms is to monitor suppression dur-
Instructions
ing convergence training. This monitormg s
1. Put on the crossed-polarizing spectacles intended to elimnate central (foveal) suppression
and look at the televisin screen from a dis during reading while the vergence system is
tance of approximately 40 n. (1 m). under stress from prismatic demands, particularly
2. Place the special sheet in front of the to elimnate suppression with BO demand. Of
screen and watch the TV show through the great purpose also s the development of good
sheet while you are wearing the special vergence facility.
524 Chapter18
and try to read the sentences quickly and 3. "Look at the distant target and try to notice
accurately. Your goal s to accomplish this that the near object, your pencil, will
without any letters or words disappearing. appear to be doubled. This is what s called
3. Next, place a prism over your left eye, as physiologic diplopia."
you were so directed n the office, and con 4. "When you are able to see the pencil appear-
tinu reading, just as before, without any ing to be doubled and the distant target s
letters or words missing. framed by the two pencil mages so that the
4. Now you will wear a prism over each eye target s exactly n the center of the pencil
and try to continu the training technique images, try to hold that perception as I place
as before. BO prism before your eyes."
5. Take off the prisms and, instead, look through 5. "I will add greater powers of prism while
prisms that are in a holder. Flip the prisms as you hold the framed perception."
you did in the office. Your goal is to see the 6. "Now that you can do this task with a cer-
words clearly and singly, as quickly as possi- tain amount of prism power, I will change
ble, with each flip. direction of prism demand by alternating it
6. As you do the prism flipping, you can also from Bl to BO to Bl, and so on."
trombone the page of print closer to you 7. "I want you to be able to perform at least 30
and then farther away. Your goal is to have flips per minute as an ideal training goal."
clear, single visin without any loss of let
ters or words.
Home Vision Training
Instructions
VERGENCE ROCKFRAMING
1. Look at a target across the room and be
AND PRISMS (T14.18) sure you see t clearly and singly.
Purposes 2. Hold a pencil n front of you approximately
The main purpose of vergence rock while framing is to 16 inches away, which s nearly 40 cm.
break suppression when viewing s at far. Framing at 3. Look at the distant target and try to notice
far is analogous to bar reading at near. In addition to that the near object, your pencil, will appear
developing a good BO fusin range at far, good ver- to be doubled.
gence faciiity can be attained by flipper-prism rock. 4. Try to place the two pencil images on
either side of the distant target. The distant
target should be centered between the two
Equipment pencils so that it looks like it is framed.
The patient holds a pencil while viewing a distant 5. When you are able to see the pencil appear-
target, such as a lightbulb. Prisms, such as lose ing to be doubled and the distant target
prisms, are used in the BO orientation. Flipper framed by the two pencil images so that the
prisms, as shown in Figure 13-12, are also used in target is exactly in the center of the pencil
this training technique. images, try to hold that perception as you
place a BO prism before one of your eyes.
6. Add greater powers of prism while you hold
Recommended Office
the framed perception. You can have your
Vision Training Instructions "helper" put a BO prism before both eyes.
The pencil or a suitable pointer stick is held by the 7. Now that you can do this task with a cer-
patient in midline straight ahead at a distance of tain amount of prism power, as prescribed
approximately 40 cm. The patient fixates on a dis- by your doctor, change direction of the
tant object, such as a lightbulb or a penlight. Rec- prism demand by alternating it from Bl to
ommended oral nstructions follow: BO to Bl, and so on. Do this with flipper
1. "Please look at the penlight target across prisms with powers prescribed by your
the room and be sure you see t clearly and doctor.
8. You should be able to perform at least 30
singly."
flips per minute while framing, as an ideal
2. "Hold the pencil in frontof you approximately
training goal.
16 in. away, which is nearly 40 cm."
chapteri9 / Vision Training for Saccades, Pursuits,
and Accommodation
Electronic Fixation Instruments for Saccades Home Vision Training Instructions 531
(T16.12) 527 Purposes 527 Marsden Ball (T16.14) 531 Purposes
Equipment 527 Recommended 531 Equipment 531 Recommended
Office Vision Training Office Vision Training
Instructions 528 Instructions 531
Continuous Motion for Saccades (T16.6) 528 Home Vision Training Instructions 532
Purposes 528 Equipment 528 Flashlight Chase (T16,17) 532 Purposes
Recommended Office Vision Training 532 Equipment 533 Recommended
instructions 528 Office Vision Training
Home Vision Training Instructions 529 Instructions 533
Ann Arbor (Michigan) Tracking (T10.7) 529 Home Vision Training Instructions 533
Purposes 529 Equipment 529 Hart Chart Near-Far Rock (T16.22) 533
Recommended Office and Home Vision Purposes 533 Equipment 533
Training Instructions 529 Recommended Office Vision Training
Sequential Fixator (TI 6.10) 529 Instructions 533
Purposes 529 Equipment 530 Home Vision Training Instructions 537
Recommended Office Vision Training Plus- and Minus-Lens Rock (TI6.23) 537
instructions 530 Purposes 537 Equipment 537
Home Vision Training Instructions 531 Recommended Office Vision Training
Standing Rotator for Pursuits (T16.13) 531 Instructions 537
Purposes 531 Equipment 531 Monocular 538
Recommended Office Vision Training Binocular 538
Instructions 531 Home Vision Training Instructions 538
Other Training Techniques 538
CONTINUOUS MOTION
FORSACCADES(T16.6)
Purposes
The purposes of continuous motion for saccades
ar to improve saccades, either gross or moder-
ately 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 The equipment for continuous motion for saccades
custom-made worksheet for beginning patients using only 10 num-
consists simply of an ordinary blank page of paper
bers. b. The same worksheet showing performance of a patient.
and a pencil. Various worksheets can be custom-
made. (Figure 19-1 shows an example of a
patient's performance; see also Figure 16-4.) An
Recommended Office Vision eye patch is used for initial monocular training.
Training Instructions
Only some examples of nstructions are given
because the number of possible variations in train- Recommended Office Vision
ing with such nstruments is almost infinite. Training Instructions
Recommended oral nstructions follow: Ask your seated patient to look at the worksheet on
the table and to pick up the pencil to begin the
1. "Wear a patch over one eye and stand in
exercise. Instruct the patient to practice good ergo-
front of the Saccadic Fixator. Turn on the unit
nomics as to working distance, good posture, and
using the flip switch on the right-hand side
proper pencil grip. Instruct the patient to encircle
panel. Position the Saccadic Fixator so that
the number 1 and then draw a straight line to num-
the central green iight is at your eye level."
ber 2 and circle it. The circling should be in a
2. "On the right-hand side panel set the sound
counterclockwise motion, and as many revolutions
to A, the mode to 1, and the time to 60."
as necessary are allowed for each number. In the
3. "Push the button next to the red Iight. For
example that follows, only two revolutions were
each button pressed correctly, you get 1
required for number /, but four were needed for
point. When the green light goes out, the
number 2. Have the patient continu through the
60 seconds are up. Note your score. Use
numeric sequence until all the numbers are cir-
the central red button to reset the unit.
cled. Instruct the patient to keep the pencil on the
Challenge your score and start again."
page at all times and ask him or her to maintain
Follow the foregoing i nstructions for patients to the pencil movement continuously and at approxi-
demnstrate a training approach with the wall mately the same speed. The counterclockwise
Chapter19 529
abcdefghijklmnopqrstuvwxyz abcdefghijkimnopqrstuvwxyz
Arom bixto. Heen dolk roche hekis tuv yiho koder ixto. Heen dolk rgQhe hekis tuv viho
quop fittin phox. Qull gump burs chom maj yaril trun qiiopfflttin phox
jub naboy zaw boken lete. Naden bom razew nush zaw bo^endgte- Ngdan hoift razewflush
harb tufid. Zoy cate gud gult. Pamel gues quim flek atR gud. gult. 3amel ques iflyimJIfi
remb caw. Dil sauf delm gaton. Fliz bluke jeg bol gmicaw. Dil gauf delm a^Oan. Flz b^nke |eqbol
nime hovic pidar mok newek dep tae frax. Basy curit Oic pidar mok netfjekjepjane fr3?8. Baaycurit
loid zarimp.
_Js_Min__2o_Sec.
Min ^Sec.
Actlvlty #10
Grele every "at," "be," and "from" n the section below. You will find at least
one oflhese words on every line.
532
laterally and have the patient track t while you backward from 100 by threes (100, 97, 94,
observe the eye movements. Give your patient feed- 91, 88, etc.). Let's try counting backward by
back about naccuracies and head movements. twos (100, 98, 96, etc.), as this may be eas-
Motor support can be added f there s difficulty; have ier for you."
your patient point to the target being tracked. Have
your patient track with the other eye and then binoc-
ularly. Observe your patient's performance with each
eye and binocularly in terms of accuracy, smooth-
ness, speed, head movement, and posture.
Recommended oral nstructions follow:
1. "Please place this patch over your left eye."
2. "Let the ball swing back and forth in front of
you. Your job is to follow the ball with your
eye. Keep your eye movements smooth and
your head still."
3. "Remove the patch, put t on your right
eye, and perform the technique."
4. "Now perform this technique with both eyes."
5. "Please keep following the swinging ball
with your head motionless and try to count
6. "Let's repeat that exercise but do it standing
on one foot."
2 4 6 8 10
1 0 F N P V D T C H E
Y B A K O E Z L R X
3 E T H W F M B K A P
B X F R T 0 S M V C
5 R A D V S X P E T 0
M P O E A N C B K F
7 C R G D B K R P M A
F X P S M A R D L G
9 T M U A X S 0 G P B
H 0 S N C T K U Z L
E T H W F H B K A P
M P 0 E A N C B K F
H O S N C T K U Z L
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 535
20/20
\
Z 4 ^7 10
A O F N P V D T C H E
Y B A K O E L L R X
C E T H W F M B K A P
b B X F R T O S MV C
E R A D V S X P E T o
r MP O E A N C B K F
& C R G D B K E P MA
u F X P S M A R D L G
T T M U A X S O GP B
T H O S N C T K U Z L
536 Chapter19
Second 100
1 2 3 4 5 6 7 8 9 10
put now new may many ate wish again want any
A
always would ask upon about us could where does tell
B
found take first say how out once long or bring
C
been only done open every never goes mus much pul
D
where sit their show work small very these think which
E
those buy own draw keep drink kind find just fll
F
grow not hold off why pretty well please use pick
G
read shall six today try better light beat hurt both
H
&r clean five cut four eight fill laugh warm right
I
white sleep write seven wash start thank sing before read
J
c
Dolch Basic Sight Words
Second 100 Answers
1 2 3 4 5 6 7 8 9 10
O-put F-now N-new P-may V-many D-ate T-wish C-again H-want E-any
A
Y-always B-would A-ask K-upon O-about E-us Z-could L-where R-does X-tell
B
E-found T-take H-first W-say F-how M-out B-once K-long A-or P-bring
C
B-been X-oniy F-done R-open T-every O-never S-goes M-must V-much C-puIl
D
R-where A-sit D-their V-show S-work X-small P-very E-these T-think O-which
E
M-those P-buy O-own E-draw A-keep N-drink C-tnd B-find K-just F-fall
F
C-grow R-not G-hold D-off B-why K-pretty E-welI P-please M-use A-pick
G
F-read X-shall P-six S-today M-try A-better R-light D-beat L-hurt G-both
H
T-fr M-clean U-five A-cut X-four S-eight O-fall G-Iaugh P-warm B-right
I
H-white O-sleep S-write N-seven C-wash T-start K-thank U-sing Z-before L-read
J
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 near-
point of accommodation. The patient altrnales fixation from the Hart Chart that shows letters to the Dolch words and calis out correspond ing let-
ter-word combinations horizontally across the row. This performance should be timed and recorded. If the patient gets lost, the c oach 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
power and attempt to clear the next letter. Observe 5. "Continu until I indcate that you should
your patient's performance in terms of ability to stop."
clear the letters with the plus and minus lenses and
the speed of clearing. Use the highest power that Binocular
presents a reasonable challenge. You can time the
1. "Please wear these polarized filters (over
technique for 1 minute to get a quantitative ndex of
your glasses, if you wear them ordnarily)
performance. (Record results in cycles per minute.)
and place ths bar reader over the printed
Repeat the exercise with the other eye.
page. Look at the gray bars. What happens
Describe your patient's performance for each eye
when I cover ths eye?" (Cover the right eye;
and note which lens was more difficult, which eye
the patent should indcate the bars that
performed better, whether working distance was
blacken.) "Now whch bars blacken when I
maintained, what powers were used, the cycles per
cover the other eye?" (The patient should
minute, and any subjective comments by the patient.
indcate that the other bars blacken.) "Let
After your patient s proficient monocularly, train
me know whether any bars blacken durng
accommodative facility binocularly by having your
this trainng technique, because that would
patient wear either the polarized or the red-green fil-
tell me you are suppressng one eye."
ters and place the appropriate bar reader over the tar-
2. "Now try to clear the first words through
get. First, demnstrate what the target will look like if
these lenses. What did you feel your eyes
suppression should occur, by covering each eye alter-
had to do to clear that letter? Now flip to
nately and asking which bars of the bar reader
the other lenses and try to clear the next
blacken. When the right eye is covered, different bars
words. What did you feel your eyes had to
should blacken than when the left eye is covered. Tell
do to clear that letter? Be sure to tell me f
your patient to notice when any bars blacken, as that
any of the bars ever blacken."
indicates that one eye is suppressing. Choose a low-
3. "As soon as the words are clear, read them
power flipper to begin. Have your patient view the
aloud and then flip the lens and clear the
target binocularly and attempt to clear t, being sure
next words. Continu until I indcate that you
that suppression does not occur. If suppression does
should stop."
occur, ask your patient to try to break suppression by
4. "If suppresson occurs, which bars black-
blinking or touching the target. Note which lenses
ened? Try to make the print behind them
(i.e., plus or minus) elicit suppression. Your patient
visible by blinking or touching the bars."
should proceed to flip the lenses and alternately view
the target through plus and minus lenses, each set,
maintaining a clear, single, binocularly viewed target. Home Vision Training
Use the highest lens power that creates a reasonable Instructions
demand. Observe your patient's performance for any
The same setup can be used for home visin train-
relative difficulty between plus and minus lenses and
ing as for office training. The goal for monocular
whether there s any suppression reported.
accommodative rock is at least 20 flips per minute,
Recommended oral instructions follow:
assuming accuracy, and at least 12 flips per minute
with binocular accuracy.
Monocular
1. "Please place this patch over your left eye."
2. "Hold this flipper and try to clear the print
OTHER TRAINING TECHNIQUES
through that lens. What do your eyes feel like?
Now flip to the other side and try to make the Refer to PartTwo for other techniques, whether for
print clear. What do your eyes feel like now?" accommodative, saccadic, pursuit, or vergence
3. "This lens is asking you to 'work' your focus- functions. Clinicians conducting visin therapy
ing" (point to the minus-power lens) "while can modify these to adjust for patients' needs and
this lens is asking you to 'relax' your focus- also can crate many other techniques that are
ing" (indcate the plus-power lens) "as f you variations of the basic exercises presented here.
were looking far away." For example, reading a book and alternately view-
4. "As soon as the print s clear, flip the lens and ing a distant calendar, sometimes called calendar
clear the next portion of the printed text." rock, can be used to train accommodative facility.
chapter 20 / Sequencing of Techniques and
Practice Management
Training techniques are listed in sequences as of each patient. The sequences generally follovv a
general guidelines for visin therapy (VT). Assum- course from easy to difficult so that success can
ing the worst-case scenarios, amblyopia s treated build on success. This chapter also includes dis-
first, then strabismus, followed by visin effi- cussions of practice management principies in
ciency training sequences according to the needs various clinical settings.
chapter20 / Sequencing of Techniques and
Practice Management
Training techniques are listed n sequences as of each patient. The sequences general ly follow a
general guidelines for visin therapy (VT). Assum- course from easy to difficult so that success can
ing the worst-case scenarios, amblyopia s treated build on success. This chapter also ncludes dis-
first, then strabismus, followed by visin effi- cussions of practice management principies in
ciency training sequences according to the needs various clinical settings.
540 Chapter 20
T14.2
T14.3
Establish physiologic diplopia
T14.5 Brock string and beads
Increase fusional convergence
T14.4 Bernell Mirror Stereoscope
T14.7 Brewster stereoscope, isometric and step ver-
gences
T14.8 Brewster stereoscope, tromboning push-aways
T14.10 Vectograms and Tranaglyphs, convergence
walk-aways
T14.11 Vectograms and Tranaglyphs, projected base-
out (BO) sudes
T14.16 Televisin trainer and prisms
T14.20 Computerized convergence training
542 Chapter 20
Pursuit Dysfunction
Improve eye-hand accuracy and speed Hyperphoria
T16.13 Automatic rotating disks (e.g., Peg-board
rotator) Increase vertical vergence ranges and facility
T16.14 Swinging (Marsden) ball T16.24 Vertical step vergence
T16.15 Penlight pursuits (or hand-held toys) T16.25 Variations on vertical vergence training
T16.17 Flashlight spot chasing
Improve pursuit accuracy and speed
T16.16 Pie-pan pursuits
T16.18 Minivectograms and Minitranaglyphs Stereopsis Deficiency
T16.19 Computerized pursuits
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 PRACTICE MANAGEMENT
T16.23 Lensrock 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 prac-
tice dedicated solely to VT; (2) prvate general
practice that ncludes VT; (3) prvate general prac-
tce wth a part-time VT specialist as an indepen-
dent contractor; (4) group practice with a VT
specialst; (5) clinic of an optometric school;
and (6) optometrist in an ophthalmologic office.
The authors have worked n most of these
clinical set-tings. Our dscussions are lmited to
VT pertaning to binocular anomalies.
544 Chapter 20
Appendix A
POLICY STATEMENT
People at risk for learning-related visin problems
should receive a comprehensive optometric evalua-
tion. This evaluation should be conducted as part of
a multidisciplinary approach in which all appropri-
ate reas of function are evaluated and managed.
The role of the optometrist when evaluating peo-
ple for learning-related visin problems s to con-
duct a thorough assessment of eye health and visual
functions and communicate the results and recom-
mendations. The management plan may include
treatment, guidance, and appropriate referral.
The expected outcome of optometric interven-
tion s an improvement n visual function with the
alleviation of associated signs and symptoms.
Optometric intervention for people with learning-
related visin problems consists of lenses, prisms,
and visin therapy. Vision therapy does not directly
treat learning disabilities or dyslexia. Vision ther-
apy 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 pro-
cess. The three nterrelated reas of visual function
are
1. Visual pathway integrity, including eye
health, visual acuity, and refractive status
2. Visual efficiency, including accommoda-
tion (focusing), binocular visin (eye team-
ing), 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 learn-
ing difficulties. Current research ndicates that
some people with reading difficulties have coexist-
ing visual and language processing dficits. For
this reason, no single treatment, profession, or dis-
550 Appendix A
cipline can be expected to address all of their visual defects that influence learning, affecting dif-
needs adequately. ferent people to different degrees. Vision is a multi-
Unresolved visual dficits can impair the ability faceted process and its relationships to reading and
to respond fully to educational instruction. Manage- learning are complex. Each rea of visual function
ment may require optical correction, visin therapy, must be considered n the evaluation of people
or a combination of both. Vision therapy, the art and who are experiencing reading or other learning
science of developing and enhancing visual abilities problems. Likewise, treatment programs for learn-
and remediating visin dysfunctions, has a firm ing-related visin problems must be designed indi-
foundation n visin science, and both its applica- vidually to meet each person's unique needs.
tion and efficacy have been established in the scien-
tific literature. Some sources have erroneously
associated optometric visin therapy with contro-
versia! and unfounded therapies and equate eye
SUMMARY
defects with visual dysfunctions. Vision problems can and often do interfere with leam-
The eyes, visual pathways, and brain compose ing. People at risk for learning-related visin problems
the visual system. Therefore, to understand the should be evaluated by an optometrist who provides
complexities of visual function, one must look at diagnostic and management services in the rea. The
the total visual system. Recent research has dem- goal of optometric intervention s to improve visual
onstrated that some people with reading disabili- function and alleviate associated signs and symptoms.
ties have dficits n the transmission of nformation Prompt remediation of learning-related visin prob-
to the brain through a defective visual pathway. lems enhances the ability of children and adults to
This creates confusin and disrupts the normal perform to their full potential. People with learning
visual timing functions in reading. problems require help from many disciplines to meet
Visual defects, such as a restriction n the visual the learning challenges they face. Optometric
field, can have a substantial impact on reading involvement constitutes one aspect of the multidis-
performance. Eyestrain and double visin resulting plinary management approach required to prepare
from convergence insufficiency can be a signifi- the individual for lifelong learning. Note: Citations
cant handicap to learning. There are more subtle from the original report are not ncluded here.
Appendix B 551
Appendix B
Developmental History
Child's ame ______________________ Birthday. -Age.
Grade ____ School's ame and address
Teacher's ame ___________________ Nurse's ame
Mother's ame ____________________ Phone
Occupation _
Father's ame _____________________ Phone
Occupation _
Mailing address ____________
Who referred you to this clinic? Number of children in family
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
1. Is your child having problems in school?
2. Does your child like the teacher?
3. Is school satisfied with child's performance?
4. Are you satisfied with child's performance?
5. Do grades really show his or her ability?
6. Is there trouble completing written assignments?
7. Does your child lose his or her place while reading?
8. Does vour child misread words that are known?
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.
V. Physical Development: At what age n years and months did the child:
VI. School Progress: Rate your child's progress n the following subjects:
Have other family members had difficulties learning any of the above subjects?
Does your child have memory difficulties? No ____ Yes ____ If so, what type of nformation?
Appendix B 553
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:
Thank you.
554 Appendix C
Appendix C
HISTORY
Has there ever been an eye turn? Is there now? Age when first noticed?
How often and under what conditions does the eye turn? j
To what extent is the eye turn apparent to others? Have you ever seen a single object as two?)
i
Any previous treatment? Glasses? Patching? Do you nave a relative with an eye turn?
!
Ages?
Exercises? Surgery?
Type?
Results?
RE LE Date By
ACUITY
CONFRONTATION
Rx at m
Altrnate RE fixating
LE fixating
(Unilateral neutralization):
Retinal correspondence (without bifixation) Sensory and motor fusin and suppression
Other results
DIAGNOSIS
Oculomotor deviation with following Rx:_________ RE LE
At m: At m: Magnitude
Magnitude Direction Freq. of Direction Freq. of
ASSOCIATED CONDITIONS
Monocular fixation Amblyopia
Fusin Ametropia
Recommendations
Instructor's Signature
Source: Modified from form used at the School of Optometry, University of California, Berkeley.
556 Appendix D
Appendix D Stereoacuity
Calculations
OS &OD
Eta = (206,000)
I.P.D. (x) d2
x x+d
dsplacement I.P.D.
x x + 400
T 60
59x = 400 x
= 6.78 mm
60(6.78)
Eta = (206,000)
(400)2
Appendix E
1 034' 1 1.75
2 09' 2 3.49
3 143' 3 5.24
4 2 17' 4 6.99
5 2 51' 5 8.75
6 3 26' 6 10.51
7 40' 7 12.29
8 4 34' 8 14.05
9 5 9' 9 15.84
10 5 43' 10 17.63
15 8 32' 15 26.80
20 11 19' 20 36.40
Appendix F
Appendix G
Visual Skills Efficiency Evaluation (Testing Outline)
Visual Skills Efficiency Evaluation (Testing Outline) Date: _______________________________
Patient _____________________ Age ____ Reason for Examination _____________________
Refractive data
OD OS Comments
2. SACCADIC EYE MOVEMENTS
Results
3. PURSUIT EYE MOVEMENTS
Results
4. ACCOMMODATION (e.g., insufficiency, excess, infacility, ill-sustained)
Results
5.VERCENCES
Ranges Far Bl Far BO Near Bl Near BO
Facility
Stamina
Phoria/tropia data
Nearpoint of convergence (n centimeters)
Results (one trial and after five triis)
Fixation disparity
Results
6. SENSORY FUSIN (ortho demand) at farpoint and at nearpoint
Fat fusin s suppression
Stereoacuity (specify tests used)
7. OTHER SENSORIMOTOR FUSIN RANGES (e.g., s suppression, s loss of stereoacuity, s fixation
disparity, s discomfort)
Results
8. DIAGNOSIS
9. PROGNOSIS
10. RECOMMENDATIONS AND ADVICE GIVEN
Appendix H 559
Appendix H
Visual Skills Efficiency Pass-Fail Gritera (Summary from
Previous Chapters)
OCULOMOTOR SYSTEMS OF POSITION MAINTENANCE,
PURSUITS, AND SACCADES
ACCOMMODATIVE SYSTEM
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.
560 Appendix H
VERGENCE SYSTEM
Nearpoint of convergence Break>8cm, fail; recovery >11, fail; approx. same vales for stamina (afterfive triis). If, how-
(NPC) ever, 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 Far 0-2 exo (otherwise possible fail)
Near 0-6 exo (otherwise possible fail)
Other phoria magnitudes are allowable, if opposing vergence blurpoints are twice the
phoria magnitude
Facility 8 BO/8 Bl at near, <5 cycles per minute, fail (with suppression check) 8
BO/4 Bl at far, <5 cycles per minute, fail (with suppression check)
Fixation disparity Any fixation disparity; consider possibility of failure; consider shape of forced vergence
curve
NFC PFC Far, <6/4; near, <12/20/11 Far,
<8/16/9; near, <15/19/8
Bl = base-in; BO = base-out; NFC = negative fusional convergence; PFC = positive fusional convergence. *Hayes
GJ, Cohn BE, Rouse MW, DeLand PN. The nearpoint of convergence. Optiom Vis Se/. 1988;75:506-512.
SENSORY SYSTEM
Appendix I
Visual Symptoms Survey
ame _______________________________________________ Age. Date
Please rate the frequency of experiencing these visual symptoms:
Never (0) Rarely (1) Somet mes (2) Frequently (3) Always (4) Unknown (U)
Headaches* (0) (1) (2) (3) (4) (U)
Blurred visin at far (0) (D (2) (3) (4) (U)
Blurred visin at near (0) (1) (2) (3) (4) (U)
Appendix J King-DevickTest
Macular IntegrityTester (MIT)
Mirror Stereoscope (Wheatstone)
Suppliers and Equipment Optokinetic Nystagmus Prism
Other equipment for binocular testing and training
Prisms
AcademicTherapy Publications Rotation Trainer
20 Commercial Boulevard Single Oblique Stereoscope
Novato, CA 94949 Tel: 800- Striated (Bagolini) lenses
422-7249 Fax:415-883-3720 Televisin Trainer
Ann Arbor (Michigan) Tracking and various visin Test Lantern for Fixation Disparity
therapy and educational material Translid Binocular Interaction Trainer (TBI)
J
Self-Assessment Test
These questions are clinical so that practitioners Panum's reas are stimulated by the displacement
can apply their theoretical knowledge to the testing of the smaller crcle relative to the larger circle.
and treating of patients. Answers and pertinent
a. nearer than, temporal
explanations are provided at the end of the section.
b. farther away than, temporal
These questions and answers can be helpful to stu-
c. nearer than, nasal
dents taking courses in binocular visin and to
d. farther away than, nasal
those preparing for board examinations related to
e. at the same distance as, corresponding
binocular anomalies and their diagnoses and thera-
pies. For easy referencing, al I questions and
answers sequentially follow the text from Chapter 1 Chapter 2
through Chapter 16. 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
QUESTIONS be defined as the presence of _________ .
Chapter 1 a. 20 cm, some undershooting
1.1. A valu of having normal binocular visin s b. 25 cm, some undershooting
having c. 20 cm, any overshooting
d. 25 cm, any overshooting
a. good stereopsis for depth perception.
e. 40 cm, any uncontrolled head movement
b. an eye in reserve, as in the spare-tire concept.
c. a larger field of visin than that of one eye. 2.2. On the Developmental Eye Movement test,
d. binocular visual acuity that is better than the patient's time, in seconds, for the horizontal
monocular acuity. array of 80 numbers (subtest C) was 75 seconds;
e. all of the above advantages. there were 2 addition errors, 2 transposition errors,
10 omission errors, and 6 substitution errors. The
1.2. Your patient fixates a target at 6 m and sees
adjusted horizontal time would be
diplopic mages of an object at 40 cm in the mid-
line of gaze. This is an example of _________ a. 65.
diplopia and the doubled image seen by his right b. 73.
eye would be seen to his _________ side as c. 75.
though he had _________ with __________ d. 80.
diplopia. e. 83.
a. physiologic, right, exotropia, pathologic 2.3. Objective testing of pursuit eye movements
b. physiologic, left, exotropia, pathologic is done, for example, with the 4+ system. In per-
c. pathologic, right, esotropa, physiologic forming this test, a target viewed at a distance of
d. pathologic, left, exotropia, physiologic cm s moved for one cycle in the hori
e. physiologic, right, esotropa, pathologic zontal direction, the vertical direction, and two
_________ orientations, and passing (3+ or better)
1.3. Refer to Figure 13-18 showing Keystone
would be ndicated by _________ .
Eccentric Greles beng used for orthopic fusin, in
which the patient is fixating a more distant target a. 40, diagonal, one fixation loss
but yet s able to fuse the set of two into one image b. 25, diagonal, no fixation loss
with clarity and perception of stereopsis. The c. 40, circular, two fixation losses
smaller fused circle will appear to be _________ d. 25, circular, two fixation losses
the larger fused circle, because _________ e. 40, diagonal, two fixation losses
568 Self-Assessment Test
adequate ranking for either distance would be 3.3. Your esophoric patient has a positive relative
________ cycles per minute. convergence of 24A and a negative relative conver-
gence of 9A. According to Percival's criterion, the
a. 4A base-in and 8A base-out, 8A base-in and 8A
ndicated relieving prism prescription would be
base-out, 5-10
_________ prism diopters base- _________ .
b. 4A base-in and 4A base-out, 8A base-in and 8A
base-out, 5-10 a. 2, n 2, out
c. 8A base-in and 4A base-out, 4A base-in and 8A b. 4, n 4, out
base-out, 5-10 c. 6, in
d. 8A base-in and 8A base-out, 8A base-in and 8A d.
3.4. Fixation disparity testing can be accomplished
base-out, 3-4 e.
with instruments such as the Disparometer or the
e. 4A base-in and 8A base-out, 8A base-in and 8A
Saladin Card. With testing at a viewing distance of
base-out, 3-4
40 cm, the patient perceives approximately 5-min-
2.14. In sensory fusin testing, stereopsis s utes-of-arc displacement of the vertical unes n the
referred to as ____ fusin. An example of a exo direction. When a demand of 6A base-in is
test for global stereopsis using crossed-polarizing ntroduced, the patient perceives the vertical unes
filters s the _________ ; one that does not require in exact vernier alignment. The associated phoria
the filters s the _________test. s_________ prism diopters and is also called the
_________ , and the angle of fixation disparity
a. first-degree, Stereo Reindeer test, Frisby
(angle F) is also known as the _________ .
b. second-degree, stereo tests (Fly), Lang
c. third-degree, Randot Stereotest, Lang a. O, dissociated phoria, Xintercept
d. third-degree, Stereo Reindeer test, Lang b. 5, X intercept, Vintercept
e. first-degree, Random Dot E Stereotest, Frisby c. 6, dissociated phoria, Y intercept
d. 6, Xintercept, Y intercept
e. 5, Y intercept, X intercept
Chapter 3
3.1. The relation between accommodative-con- 3.5. Vergence anomalies with a high AC/A ratio are
vergence and accommodation (AC/A) is a ratio that _________ and _________ .
can be calculated from far and near phorias. For a. basic eso, divergence insufficiency
example, a patient has 15 A of exophoria at 6 m b. basic eso, convergence excess
and s orthophoric at 40 cm. The calculated AC/A c. divergence excess, convergence excess
ratio, assuming a 60-mm nterpupillary distance, is d. basic exo, divergence excess
_________ . If the gradient AC/A method were to e. divergence nsufficiency, divergence excess
be used, the ratio would Nkely be _________ .
a. 6/1, higher Chapter 4
b. 8/1, lower 4.1. The most mportant diagnostic variable of
c. 10/1, higher the deviation to be evaluated n strabismus is
d. 12/1, lower _________ , and the second most mportant s
e. 6/1, lower
3.2. In graphically plotting the zone of clear, sin a. frequency, magnitude
gle binocular visin, the positive relative conver- b. comitancy, magnitude
gence is measured relative to the __________, is c. eye laterality, frequency
designated by a _________, and would be plotted d. comitancy, frequency
on the_________ side of the phoria Une. direction of deviation, magnitude
e.
a. demand line, circle, right
b. phoria valu with an X designation, circle, 4.2. Your patient has a left hypertropia that
right increases on dextroversion and further ncreases
c. demand line, square, left on right head tilt. The suspected isolated paretic
d. phoria valu with an X designation, square, right extraocular muscle is the _________ .
e. demand line, circle, left
570 Self-Assessment Test
a. left superior rectus ter of the fovea, the magnitude of the angle of eccen-
b. right superior rectus tric fixation (angle ) most exactly is classified as
c. left superior oblique
d. ieft inferior rectus a. central.
e. right inferior oblique b. fovea I.
c. parafoveal.
4.3. The diagnostic variables of strabismus that d. macular.
relate to frequency are constant and ________ , e. peripheral.
and those that relate to eye laterality are _________
and _________ . 5.4. Your patient has amblyopia of the left eye with
a +0.5-mm angle kappa and a nonamblyopic right
a. alternating, unilateral, intermittent eye with a +1-mm angle kappa. From this informa-
b. unilateral, ntermittent, alternating tion, you determine that the type of deviation s
c. alternating, ntermittent, unilateral
d. unilateral, alternating, intermittent a. esotropa of the left eye.
e. intermittent, unilateral, alternating b. eccentric fixation of both eyes, but less eccen
tric in the left eye.
4.4. An esotropic patient has strabismus of 12A at
c. nasal eccentric fixation of the left eye.
far and near. Cosmesis is favored if the patient has a
d. nasal eccentric fixation of the right eye.
a. positive angie kappa and a narrow bridge of e. esotropa of the right eye.
the nose.
5.5. In cases of amblyopa, ophthalmoscopic
b. wide face and a negative angle kappa.
evaluaton with dilated pupils and testing of visual
c. positive angle kappa and a wide bridge of the
fields, neutral-density filters, and Farnsworth panel
nose.
D-15 are important for detecting
d. negative angle kappa and a wide bridge of the
nose. a. eccentric fixation.
e. negative angle kappa and a narrow bridge of b. unsteady fixation.
the nose. c. anomalous correspondence.
d. suppression.
Chapter 5 e. ocular disease.
5.1. You test your strabismic patient for suppres- 5.6. You have a patient with angle H of 25A eso
sion. Based on the naturalness of conditions, the and angle S of 25 A eso. Your next patient has an
test most likely to detect suppression would be the angle H of 25A and angle S of 0A. The first patient
a. Pola-Mirror. has , and the second patient has
b. Brewster stereoscope and stereograms.
c. Wheatstone stereoscope and stereograms. harmonious anomalous retinal correspondence
d. penlight with red-green filters. (HARC), normal retinal convergence (NRC)
e. Maddox rod test. unharmonious anomalous retinal correspon-
5.2. Probably the most effective visual acuity test dence (UN HARC), NRC NRC, HARC NRC,
for an amblyopic eye that takes into account the c. UNHARC HARC, UNHARC
effect of the crowding phenomenon as well as an d.
indefinite acuity threshold and avoids the problem e. 5.7. The inability to obtain binocular fusin or
superimposition of haploscopically presented tar-
of guessing is the gets or the condition or phenomenon itself s
a. Snellen chart.
a. anomalous retinal correspondence.
b. Bailey-Lovie chart.
b. suppression.
c. psychometric chart designed by Flom.
c. amblyopia.
d. Tumbling E.
d. horror fusionis.
e. picture cards.
e. eccentric fixation.
5.3. If your patient has eccentric fixation, with point
e being on the nasal retina 1.5 degrees from the cen-
Self-Assessment Test 571
5.8. Your patient has constant unilateral esotropa 6.3. Your patient is 7 years od and has comitant,
of the right eye of 15 A with HARC, and you per- intermittent (10% of the time at far and 90% at
form the Hering-Bielschowsky afterimage test in near), unilateral esotropa of the right eye of 6A at
the recommended manner. You would expect the far and 16A at near and has normal retinal corre-
vertical afterimage perceived by the patient to be spondence and some stereopsis, but there is shal-
low central suppression. The prognosis for a
a. exactly centered in respect to the horizontal
functional cure is theoretically
afterimage.
b. 15A to the left of the horizontal center. a. poor.
c. 15A to the right of the horizontal center. b. poor to fair.
d. 30A to the left of the horizontal center. c. fair.
e. 30A to the right of the horizontal center. d. fair to good.
e. good.
5.9. Your patient has esotropa of 24A at far and 34A
at near and has a 60-mm nterpupillary distance. You
wsh to test at the patient's centration point, for Chapter 7
example, with the Worth four-dot test or with Vecto- 7.1. Some characteristics of primary comitant
grams. The distance of the centration point from the esotropa are age of onset _ _____ and refrac-
patient would be _________ centimeters, and the tive error ndicating ___ In additon,
plus add would be ________ diopter(s). anomalous retinal
correspondence ________________________ .
a. 10,1.00
b. 15,2.00 a. at birth or shortly after, hyperopa, is almost
c. 20, 3.00 always present
d. 25,4.00 b. after 6 months, no ametropia, may or may not
e. 30, 5.00 be present
c. at birth, hyperopia, is almost always present
d. after 6 months, hyperopia, may or may not be
Chapter 6 present
6.1. Functional cure of strabismus, according to e. at brth, little or no ametropa, s almost always
Flom, means that the patient has bifoveal fixation present
_________ percent of the time, clear visin that is 7.2. Sensory strabismus refers to loss of sensory
_________ comfortable, and bifixation n all fields fusin, particularly if visual acuity of one eye s
of gaze and distances as cise as _________ cen severely reduced. The direction of the eye turn is
timeters from the eyes and that corrective lenses related to the age of onset, such that onset after the
can be worn with the amount of relieving prism age of __________ year(s) usual ly results in
being _________ prism diopters.
a. 95, always, 8, 5 a. 1, exotropia
b. 99, generally, to the nose, 5 b. 2, esotropa
c. 100, always, 8, 5 c. 3, exotropia
d. 95, always, to the nose, 8 d. 4, esotropa
e. 99, generally, a few, a reasonable amount of e. 5, exotropa
6.2. The cosmetic appearance of an exotropic patient
probably s better f angle kappa s ________ , there Chapter 8
are _________ epicanthal folds, the interpupillary 8.1. Paretic strabismus, as opposed to developmen-
distance is _________ , and the face is ________ . tal strabismus, s suspected in the presence of the
following six factors: mode of onset, _______
a. positive, no, large, narrow age of onset, _________; diplopia, ________
b. negative, no, large, wide head posture, _________ ; amblyopa, ________
c. positive, noticeable, small, narrow and retnal correspondence, _________ .
d. negative, noticeable, small, wide
e. positive, no, small, narrow a. sudden, any age, common, abnormal, rare,
normal
572 Self-Assessment Test
muscle surgery with the hope of achieving good cm, with addition lenses of.
functioning binocular visin. You would advise _____ D, and the
against the operation f there is goal would be for the patient to perceve a
_________ superimposed on a penlght while
a. deep suppression.
looking at the light.
b. harmomous anomalous correspondence.
c. unharmomous anomalous correspondence. a. 15,1.50, noncross superimposed on an X
d. deep suppression and harmonious anomalous b. 40, 2.50, cross not supermposed on an X
correspondence. c. 40, 2.50, cross superimposed on an X
e. limited motor fusin ranges and harmonious d. 50, 6.00, noncross but two diagonal lines not
anomalous correspondence. forming an X
e. 50, 6.00, cross but two diagonal lines not
Chapter 11 forming an X
11.1. Your patient s 3 years od and has recently 11.5. Your patient has 20 A of constant exotropia
developed comitant, constant, alternating esotro at far and near, and the subjective angle of direc-
pa. There is no amblyopia, but the patient has tionalization (angle S) is 0 A. Your training tech-
anomalous retinal correspondence (ARC). You niques would emphasize
would initially consider
a. flashing at the objective angle using a major
a. constant unilateral occiusion between office amblyoscope.
treatments for ARC. b. flashing at the subjective angle using a major
b. ntermittent unilateral occiusion. amblyoscope.
c. ntermittent alternating occiusion. c. using base-in relieving prisms and Vectograms
d. binasal occiusion. at the subjective angle.
e. no occiusion but beginning active functional d. using base-in relieving prisms and Vectograms
training. at the objective angle.
11.2. You have a patient with constant esotropa e. push-up targets, temporary minus-addition
of 15A and ARC. The prism power that would be lenses, and afterimages.
used to break the ARC would be at least
base- ____________ . Chapter 12
a. 15, in 12.1. Your anisometropic patient has unilateral,
b. 15, out shallow, central suppression even when optically
c. 25, out corrected with either spectacle or contact lenses.
d. 30, n You give occiusion antisuppression therapy and
e. 30, out consider starting with an occluder that s
11.3. A classic technique to treat ARC with a a. a light pink lens over the nonsuppressing eye.
major amblyoscope is flashing targets at the objec- b. a light pink lens over the suppressing eye.
tive angle. Targets are _________ , and flashing s c. a dark red lens over the nonsuppressing eye.
_, n an attemptto achieve an ntermedi- d. a dark red lens over the suppressing eye.
ate stage of. e. an opaque lens over the nonsuppressing eye.
a. dissimilar, rapid and altrnate, binocular triplopia 12.2. Your strabismic patient has deep suppres
b. similar, rapid and altrnate, diplopia sion. Your choice of target n a stereoscope (prefer-
c. dissimilar, slow and altrnate, binocular triplopia ably n a major amblyoscope) for antisuppression
d. similar, rapid and unilateral, diplopia training would be characterized by _________
e. dissimilar, slow and unilateral, binocular triplopia size, _________ presentaron, __________stimu-
lus, and _________ contrast.
11.4. Your patient has constant unilateral esotro
pa of 15A at far and 20A at near with harmonious a. small, constant, moving, high
ARC. For trainng in the open envronment, you b. large, ntermittent, moving, high
elect to use afterimages and Bagolini lenses. The c. small, intermittent, stationary, low
centration point dstance would be _________ d. large, constant, stationary, high
e. small, ntermittent, moving, low
Self-Assessment Test 575
12.3. You are providing antisuppression training d. recession and resection of an eye, increase
using the Brock string and beads technique. You e. bilateral medial recession, lower
instruct the patient to view the nearest bead,
13.3. Your patient has esophoria of 15A at far and
approximately 20 cm away. The patient reports see-
5A at near. A most effective and ultmate applicable
ing only one string farther from the bead, and t is
visin training technique might be:
off to the patient's left side. This reported perception
causes you to suspect _________ suppression, and a. Brewster stereoscope push-aways.
you would consider having the patient blink the b. Brewster stereoscope push-ups.
________ eye and use _________ filters. c. walk-aways with penlight and anaglyphic filters.
d. push-ups with penlight and anaglyphic filters.
a. physiologic, left, red
e. Bernell Mirror Stereoscope base-in training.
b. pathologic, right, green
c. pathologic, left, red 13.4. The Bernell Mirror Stereoscope provides
d. physiologic, left, green vergence demands by _____________ the
e. pathologic, right, red and green angle of the instrument, which is particularly good
for convergence excess patients and can be used
12.4. You are conducting antisuppression train
for divergence insufficiency patients f _________ -
ing with the Pola-Mirror. The patient notices that
D additions are worn.
the left eye appears darkened, which indicates
_________ suppression of the left eye, and a real- a. base-in, narrowing, -3.00
istic but ideal goal s for the patient eventually to b. base-out, widening, +3.00
see with _______ at a distance of approxi c. base-in, widening, +3.00
mately _________ cm from the mirror. d. base-out, narrowing, -3.00
e. base-in, widening, -3.00
a. peripheral, either eye, 25
b. foveal, both eyes, 50 13.5. Assume the homologous points of a stereo-
c. peripheral, either eye, 50 gram for a Brewster stereoscope are separated by a
d. foveal, both eyes, 75 distance of 67 mm. You wish to give your eso
e. peripheral, either eye, 75 patient vergence demands at near (at the 2.50-D
accommodative demand). The demand at far
Chapter 13 would be _________ and at near _________ .
13.1. Your patient has esotropa of 15A at far and a. 10A base-out, 3A base-out
an nterpupillary distance of 60 mm. There s nor- b. 3A base-out, 3A base-in
mal retinal correspondence but deep suppression. c. 10A base-in, 3A base-in
Training is done at the centration point using the d. 3A base-in, 3A base-out
Brock string at a viewing distance of _________ e. 10A base-out, 3A base-in
cm, and the patient should wear addition lenses of
13.6. Your patient with convergence excess is
________ D.
given therapy with a Brewster stereoscope. Fusin
a. 20, 1.50 would likely be more _________ as the stereo-
b. 20, 2.50 gram s tromboned nearer and more _________ as
c. 40, 2.50 t s tromboned farther away, because the ortho
d. 40, 4.00 demand separation of homologous points at far s
e. 100, 1.00 _________ mm and __________ mm at near
(2.50-D accommodative demand).
13.2. Your patient has esotropa of 20A at far and
30A at near. Extraocular muscle surgery you would a. difficult, easy, 63, 87
consider efficacious would be _________ , which b. difficult, easy, 87, 63
could c. easy, difficult, 63, 87
also the accommodative- d. easy, difficult, 87, 63
convergence/accommodation ratio. e. difficult, easy, 87, 87
a. bilateral resection, lower 13.7. Your patient with basic esophoria s work-
b. bilateral medial recession, ncrease ing with the Brock string and beads. Jump ver-
c. recession and resection of an eye, lower
576 Self-Assessment Test
13.14. Your patient has microesotropia, but there has been corrected with lenses. The typical
is no amblyopia or ARC. This is _________ of most sequence of visin therapy could be
patients with microesotropia. The magnitude of the
a. training basic ocular motility of each eye, gross
objective angle of deviation is often _________
convergence training, classic ARC therapy if nec-
with the altrnate cover test than with the unilateral
essary, sensory alignment using base-in prisms
cover test because of the ________ deviation.
and minus lenses, antisuppression therapy, and
a. typical, smaller, manifest central sensory and motor fusin training.
b. atypical, larger, latent b. classic ARC therapy if necessary, training basic
c. typical, smaller, latent ocular motility of each eye, gross convergence
d. atypical, larger, manifest training, sensory alignment using base-in prisms
e. typical, larger, latent and minus lenses, antisuppression therapy, and
central sensory and motor fusin training.
13.15. Your esophoric patient has a magnitude of
c. sensory alignment using base-in prisms and
deviation of 10A at far and near. Your first treatment
minus lenses, antisuppression therapy, training
would be to prescribe __________ . Next, you
basic ocular motility of each eye, classic ARC
would prescribe __________ . If symptomatic and
therapy f necessary, gross convergence training,
performance problems are not abated you would
and central sensory and motor fusin training.
prescribe_________ .
d. gross convergence training, classic ARC therapy
a. prism compensaron (base-in), fusional diver- if necessary, training basic ocular motility of each
gence training, lenses that fully correct any sig- eye, antisuppression therapy, sensory alignment
nificant refractive error using base-in prisms and minus lenses, and cen
b. lenses that fully correct any significant refrac tral sensory and motor fusin training,
tive error, fusional divergence training, prism e. antisuppression therapy, sensory alignment
compensation (base-out) using base-in prisms and minus lenses, training
c. fusional divergence training, lenses that fully basic ocular motility of each eye, gross conver
correct any significant refractive error, prism gence training, classic ARC therapy if necessary,
compensation (base-in) and central sensory and motor fusin training.
d. lenses that fully correct any significant refrac-
14.3. The possibility of extraocular muscle sur-
^\tive error, stressing prism (base-in), fusional
gery should be considered if your patient has con-
- divergence training
stant exotropia with a magnitude greater than
e. fusional divergence training, prism compensa
_________ prism diopters or greater than
tion (base-out), lenses that fully correct any sig
_________ f the exotropia is intermittent.
nificant refractive error
a.14.2. Your patient has comitant constant
b.exotro-
Chapter 14 c. pia with anomalous retina! correspondence
14.1. Comparing exo deviations with eso devia- d.(ARC)
tions, the ratio regarding strabismus is e.but has no amblyopia. Any significant
_______________________________________ ametropia
,
with _________ deviations being more prevalent.
Increasing fusional vergence with training is rela-
tively easy when the strabismus is
_______________________________________
,
which is more common in _________ deviations.
a. 2 to 3, eso, constant, exo
b. 2 to 3, exo, ntermittent, eso
c. 3 to 2, eso, constant, exo
d. 3 to 2, exo, constant, eso
e. 3 to 2, exo, i ntermittent, exo
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 por- patient. For patients with basic exo or divergence
tion of the card excess, the mirror s moved _________ the
d. more, septum, cut off the top portion of the patient. In any of the three types of exo deviations,
card _________prism demand can be incorporated
e. less, septum, cut off the top portion of the card with the Pola-Mirror technique for additional
fusional vergence training.
14.5. Your patient with basic exophoria is per-
forming the technique of convergence walk-aways. a. closer to, farther from, base-in
At the usual distance of 40 cm, the patient can fuse b. farther from, closer to, base-out
and hold the separated Spirangle Vectogram with c. closer to, farther from, base-in
the number 72 showing through the masked bar. d. closer to, closer to, base-out
This indicates a prism demand of _________ . The e. closer to, farther from, base-out
patient walks away to 160 cm, and the prism
14.9. Presbyopic exophoria s similar to
demand s _________.
_________in younger patients. Vision training for
a. 12A base-out, 3A base-out the elderly is _________ , because the cure rate is
b. 12A base-in, 3A base-in
c. 12A base-out, 12A base-in
a. convergence insufficiency, recommended,
d. 12A base-in, 12A base-in
more than 90%
e. 12A base-out, 9A base-out
b. convergence excess, recommended, more than
14.6. Your patient with convergence insuffi- 90%
ciency is using the Aperture-RuleTrainer at home. c. convergence insufficiency, not recommended,
The patient's goal is ultimately to be able to fuse less than 50%
card 12 looking through the _________ aperture, d. convergence nsufficiency, recommended, less
which presents a _________ demand of than 50%
e. convergence excess, not recommended, less
than 50%
a. single, base-in, 12A
b. double, base-in, 24A
c. single, base-out, 24A Chapter15
d. double, base-in, 30A 15.1. Duane retraction syndrome and Brown
e. single, base-out, 30A syndrome are examples of _________ deviations
and, f anomalous retinal correspondence exists,
14.7. Binocular accommodative rock can be use-
visin therapy usually should_________ to estab-
ful n cases of exo deviations, particularly for
lish normal retinal correspondence, because of the
patients with _________ and __________ but, by
possibility of effecting _________ .
comparison, s not very effective n cases of
_________ because of the __________ accommo- a. acquired noncomitant, be attempted, a cure
dative-convergence/accommodation ratio. b. acquired comitant, be attempted, a cure
c. infantile noncomitant, not be attempted, diplopia
a. convergence insufficiency, basic exo, diver
d. acquired comitant, not be attempted, diplopia
gence excess, high
e. infantile comitant, be attempted, a cure
b. convergence insufficiency, divergence excess,
basic exo, high 15.2. Your adult patient has a recently acquired
c. basic exo, divergence excess, convergence noncomitant eso deviation. The right lateral rectus
insufficiency, low muscle is paretic. Occlusion is one form of visin
d. basic exo, divergence excess, convergence therapy that can be prescribed and initially it
insufficiency, high would consist of
e. pseudo-divergence excess, basic exo, conver
a. constant occiusion of the right eye.
gence insufficiency, high
b. constant occiusion of the left eye.
14.8. The Pola-Mirror convergence technique is c. ntermittent occiusion of the right eye.
useful for patients with convergence insufficiency, d. intermittent occiusion of the left eye.
for whom the mirror is moved ________ the e. constant altrnate occiusion.
Self-Assessment Test 579
15.3. You decide to prescribe Fresnel prism for a e. elimnate any head movement and then go
patient who has a recently acquired noncomitant from large to small saccades, slow to fast, and
eso deviation due to lateral rectus paresis of the monocular to binocular.
right eye. The best chance of preventing contrac-
16.3. A computer stereopsis enhancement tech-
ture of the right medial rectus muscle would be
nque typically uses _________ stereograms in
with
which _________ positons of the target are ran-
a. base-in prism over each eye. domly introduced and vergence demands are cre-
b. base-out prism over each eye. ated by _________ .
c. base-in prism over the left eye. a. vectographic linear, two, disparated targets
d. base-out prism over the left eye. b. random dot, two, dsparated targets
e. base-out prism over the right eye. c. vectographic linear, four, lose prsms for base-
15.4. Your patient has congenital nystagmus and in and base-out demands
a noticeable left head turn. Your prism prescription d. random dot, four, dsparated targets
to reduce the appearance of the head posture e. random dot, four, lose prisms for base-n and
would most likely be base-out demands
a. base-in for each eye. 16.4. Your orthophoric patent has symptoms sim
b. base-out for each eye. ilar to those of patients wth decreased vergence
c. base-in for the left eye and base-out for the ranges. An objective test that may reveal the cause
right eye. of the symptoms s the _________. This would ind
d. base-out for the left eye and base-in for the cate the need for trainng all vergence and accom-
right eye. modative ranges, because an orthophoric person
e. base-down for each eye. could momentarily have an _________ deviation
when looking from near to far and an _________
deviation when looking from far to near.
Chapter 16 a. static cover test, exo, eso
16.1. Aniseikonia of less than per- b. kinetic cover test, eso, exo
cent in patients s usually symptomless, c. Maddox rod test, exo, eso
whereas d. Maddox rod test, eso, exo
more than _________ percent s an obstacle that e. fixation disparity test, exo, eso
may make central fusin impossible.
16.5. The goal in visin therapy s for patents to
a. 1, 3 achieve
b. 1,5
a. clear binocular visin.
c. 3,5
b. single binocular visin.
d. 5, 7
c. comfortable binocular visin.
e. 5, 9
d. efficient binocular visin.
16.2. A general training sequence for improving e. all of the above.
saccadic eye movements would be to
a. go from large to small saccades, slow to fast,
and monocular to binocular and then to elim ANSWERS
nate any head movement.
b. go from small to large saccades and slow to
Chapter 1
fast, elimnate any head movement, and go 1.1.e. All are true. Also note that contrast sensi-
from monocular to binocular^ tivity is better binocularly than monocularly.
c. go from large to small saccades, fast to slow, 1.2.>. Refer to discussion on heteronymous
and monocular to binocular and then to elim (crossed) diplopia of an object that s nearer than
nate any head movement. the fixation target.
d. go from small to large saccades, monocular to 1.3.a. The smaller, inner fused circle should
binocular, and slow to fast and then to elim appear to be closer than the larger fused circle,
nate any head movement.
580 Self-Assessment Test
because temporal Panum's reas (relative to the indcate a rank of weak, because the amplitude is
center of the fovea of each eye) are stimulated. 2.00 D below the average for the age of 10. 2.6.e.
Refer to Figure 1-15 showing how the Ys are dis- MEM is one of the few tests of visin effi-ciency in
placed nasally in relation to the bifixated star and which the patient's viewing distance s that for
the Ys would be projected onto the retina to loca- habitual reading, and the habitual specta-cle
tions temporal to the center of the fovea. Refer to correction for reading, if any, s worn during initial
Figure 1 -16 illustrating the plus and minus symbols testing. Note that an accommodative lag of 1.00
representing crossed disparity and uncrossed dis- D or more s considered failing. 2.7.d. Any lead of
parity, respectively. accommodation on the MEM, found with a minus-
power lens, is failing when considered in regard to
excess of accommodation. 2.8. b. Normally,
Chapter 2 monocular accommodative facility is better
2.1.c. The separation should not exceed 20 cm (higher rate) than is binocular accommodative
at the near distance of 40 cm, as head movements facility because of the effect of vergences. For
may be necessary for eye movements of such example, an esophoric patient would likely have
magnitudes. Some undershooting is common, but more difficulty fusing through minus lenses than
overshooting is not normally expected. Saccades through plus lenses. 2.9.d. A breakpoint of 7-8
as small as 15 degrees or more can often genrate cm would be ade-quate for absolute convergence
some head movement. Clinicians in the past have and have a ranking of 3 on a 5-point scale.
used a 25-cm separation at 40 cm, but that Although most clinicians use only the centimeter
tended to result in head movements or under- distances for breakpoints and recoveries, the
shooting and s not considered valid testing of absolute convergence n prism diopters Ilstrales
gross saccades. the greater magnitude of absolute (gross)
2.2.e. Refer to the formula for calculation. Note convergence as compared with relative
that only the omission (O) and addition (A) errors convergence. Also, it often s helpful to know how
are taken into account n the formula. Significant much total convergence s required for various
omission errors (in the denominator) are consid- bifixation distances n both testing procedures and
ered unfavorable n that the score time is raised, training techniques.
thus making more likely its failure as to the hori- 2.10.a. Prism (vergence) adaptation can occur
zontal time. Conversely, addition errors (n the quickly on vergence demand, particularly with
denominator) lower the score time. Substitution base-out prism. Very slow sliding vergence demand
and transposition errors are not quantified n these can crate adaptation and give a falsely high finding
calculations. of relative vergence that would not ordinarily exist
under normal circumstances in daily life. In con-
( 80 Adj. trast, induction of prism demand at a rate faster than
time = test time x r^=^r 4A per second does not allow sufficient time for the
\LU U +
patient to maintain fusin effectively for testing pur-
= 7580 poses, and so a falsely low finding may result.
' 2.11.e. Base-in demand should be given first, as
72 prism adaptation is less robust than with base-out
demand. Also, at far distance (6 m), the eyes are n
= approximately 83 seconds ortho position when fusing a target and not n a
converged position as when fixating a target at
2.3.a. The recommended stimuli for pursuits is n
near, which could result in adaptation to conver-
the pattern of the British flag, which ncludes diag-
gence. A blurpoint is not normal for base-in
onal lines. One fixation loss is allowed n this test-
demand at far, assuming corrected ametropia with
ing procedure that takes approximately 10 seconds
most plus (CAMP) lenses are worn by the patient.
to complete.
Blurring would be due to failure to wear CAMP
2.4.c. Refer toTable 2-8. A ranking of at least 3 s
lenses, as in latent hyperopia or if the patient were
necessary for passing for either the 4+ on the 5-
"overminused."
point system of ranking.
2.12.d. SeeTable2-22, which shows that an ade-
2.5.b. Refer to the mnimum formula of Hofstet-
quate positive relative convergence ranking is 3
ter, in which a 10-year-old should have an ampli-
tude of 12.5 D. An insufficiency of 2 D would
Self-Assessment Test 581
5.2.c. The psychometric chart most effectiveiy nasalward (left) direction, because the fovea s 15A
allows for analysis of a plotted sigmoid curve for a n a templeward direction from point a (the anom-
criterion for acuity at the 50% level of correct alous associated point of the right eye). 5.9.d.
responses. Refer to the formula n Chapter 5 to calclate the
53.c. This is a case of nasal eccentric fixation dioptric demand and, n turn, the distance of the
and s parafoveal, the magnitude being between centration point. A +4.00-D add puts optical
the center of the fovea and point e that s eccentric infinity at 25 cm. Note that the magnitude of the
by 2 degrees or less. near deviation of the visual axes is irrelevant n this
5.4.c. Angle kappa testing is done monocularly. calculation and that the only factors are the far
Therefore, no statement can be made regarding magnitude and the interpupillary distance.
heterotropia (strabismus). An eccentric fixation is
indicated for the amblyopic left eye, because the
Chapter 6
angles kappa differ. The left eye should normally
have a +1-mm angle, but the +0.5-mm measure- 6.1.e. This s the recommendation of Flom as to
ment would mean that the left eye turned nward functional cure of strabismus. 6.2.d. Favorable
(more nasal) on fixating monocularly to reduce the cosmetic factors for an exotro-pic individual are a
angle kappa from +1 mm to +0.5 mm. There is, negative angle kappa, epican-thal folds, small
therefore, nasal eccentric fixation of the left eye. interpupillary distance, and a wide face.
Such a testing procedure s known as the Worth 6.3.e. Refer to Case 10. Factors such as intermit-
test for eccentric fixation. Although not very sensi- tency and normal retinal correspondence are pow-
tive as compared with visuoscopy, t s credited as erful indicators for a favorable prognosis. The high
being one of the first methods originated to test for accommodative-convergence/accommodation ratio
eccentric fixation. in this case of convergence excess can also be help-
5.5.e. All the testing procedures are helpful for ful if plus-addition lenses are used to relieve the
detecting eye disease. larger eso deviation at near.
5.6.c. The fact that the objective and subjective
angles are the same means there s normal corre-
Chapter 7
spondence of the retinal points. When the subjec-
tive angle s zero and the objective angle is of any 7.1 .d. Primary comitant esotropa should be distin-
other magnitude, the correspondence is anoma- guished from infantile esotropa. The main distinction
lous and harmonious. Note that we use the tradi- is the age of onset. In nfantile esotropa, the age of
tional abbreviations of NRC and HARC, whereas onset is before 6 months, whereas primary comitant
some clinicians refer to NRC, for example, as NC esotropa is after 6 months but before age 6 years.
and to ARC as AC; we believe these latter abbrevi- Prognosis is better in cases of primary comtant
ations, used n this sense, cause confusin, as they esotropa than in cases of nfantile esotropa. Some
have other connotations that are not limited to sta- patients wth primary comitant esotropa have signif-
tus of correspondence in binocular visin (e.g., cant hyperopa, and optical correction wth lenses
accommodative convergence). 5.7.d. Horror can mprove the prognosis for a functonal curve.
fusionis occurs only under binocular viewing 7.2.e. Older individuis with loss of sensory
conditions, usually only f there is strabismus with fusin tend to acqure exotropia rather than esotro-
ARC. This phenomenon can most often be pa. This is fairly common n the elderly with uni-
explained by a "notch" in the horopter. Horror lateral cataract.
fusionis may also occur n certain cases of
aniseikonia.
Chapter 8
5.8.c. The recommended manner of testing is for
the horizontal light to stimulate the fixating pre- 8.1.a. Assumng the onset of noncomitancy s
ferred eye (left eye, n this case), while the strabis- after early childhood and the patient did have nor-
mic nonpreferred eye (right eye) s stimulated with mal binocular visin, amblyopia and ARC are
the vertical line. Because there s HARC, the fovea highly unlkely after extraocular muscle paresis;
of the left eye corresponds with point a of the right however, the symptom of diplopia and the sign of
eye, which is 15A nasal to the stimulated fovea. The abnormal head posture are likely.
afterimage is, therefore, projected by the fovea in a
Self-Assessment Test 583
8.2.b. The diagnostic action field of the left supe- as inappropriately saying "jump ductions" for "step
rior oblique muscle s down, right, and ntorted to vergence."
the right. The patient would compnsate by chin 9.5,b. The chiastopic fusin technique usually is
depression, moving the face toward the right, and too advanced for a child in the preoperational
tilting the head toward the right. The compensatory stage, but the child should normally be able to
head movements are in the direction of the diag- learn the three-dot card technique while in the
nostic action field of the affected muscle. 8.3.c. later years of the preoperational stage.
The description is probably of a Duane type 1
case, which s the most common and classic type
Chapter 10
of Duane retraction syndrome. 8.4.d. Brown
syndrome is also known as tendn sheath 10.1 .c. Constant unilateral strabismus is certainly
syndrome. The limitation of the eye to move to up- a major cause of amblyopia of an eye. Probably
gaze with adduction is similar to the action of a more cases of amblyopia result, however, from
paretic inferior oblique muscle. Differential diagnosis anisometropia than from strabismus. The first con-
can be made by noting an incyclophoria (or incyclo- sideration in therapy is to correct any significant
tropia) with a paretic inferior oblique muscle but not refractive error, particularly anisometropia. In
with Brown syndrome. Diagnostic differentiation young children, bilateral astigmatism will cause
would be duction testing, observing the speed of meridional amblyopia in each eye, but a greater
movement on up-gaze and inward gaze. In Brown astigmatic error in one eye will be amblyogenic for
syndrome, the speed would be fast but limited, but that eye, as n spherical anisometropia. 10.2.b.
the speed would be slow with a paretic inferior Altrnate occlusion is necessary because the left
oblique. The forced duction test would also tell the eye s legally blind and the individual would
story. The range of motion would be full with inferior otherwise be unable to function well in daily
oblique paresis but would be restricted by the tendn Ufe. Full-time occlusion s more effective for quick
sheath in Brown syndrome. results than is intermittent patching. When the
8.5.a. The most common type of nystagmus is patient's right eye is patched, the direct occlusion
congenital, affecting males more than females. The forces the ambiyopic eye to fixate and be used.
high prevalence and the characteristics of this When the left eye is patched, the indirect
patient's nystagmus make the congenital type likely. occlusion allows for good visual acuity while pas-
A history of nystagmus in early infancy would also sively eliminating suppression. The exception to
confirm the diagnosis. 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
Chapter 9 nystagmus occurs on unilateral occlusion, and
9.1 .b. Refer to the text discussions for this histri- creating nystagmus in the ambiyopic eye during
ca! perspective. treatment is not desirable. Occluding an eye in cases
9.2.d. Refer to the text discussions for this histri- of ntermittent strabismus may be unwise, because
ca! perspective. fusin is disrupted and the frequency of the
9.3.b. Assuming a strabismic patient has both strabismus may be increased or constant strabismus
amblyopia and ARC, the amblyopia should be might develop if there is prolonged occlusion. Penal-
treated first, at least to 20/60 (6/18) acuity. Then, ization can allow for peripheral fusin and at least
treatment of ARC should be undertaken, providing some binocularity in the treatment program. 10.4.6.
the prognosis is favorable for this course of action. Monocular training s involved n these
Antisuppression therapy s not feasible when there techniques. Binocular visin s required in tech-
is ARC, at least in patients with constant esotropa; niques such as peripheral fusin rings, anaglyphic
there are exceptions, however, in cases of exotro- fusin games, and reading bars. 10.5.a. The fovea
pia with ARC. When there s normal retinal corre- can be tagged with a Haidinger brush, just as with
spondence and little or no suppression, training an afterimage, for training for central and steady
for sensorimotor fusin enhancement is then in fixation in the treatment of amblyopia. This is
order. usually done with monocular training as opposed
9.4.a. Note that some clinicians say "jump ver- to binocular training, as in antisuppression
gence" when they mean "step vergence," as well training.
584 Self-Assessment Test
10.6.>. The displacement can be calculated by 11 3.a. Superimposition (first-degree) targets are
using Griffin's decimeter rule: For each prism used n the major amblyoscope and are rapidly
diopter, the number of millimeters of displacement and alternately flashed. Diplopia should be
equals the number of decimeters of fixation dis- noticed, because the foveas are stimulated and
tance. For example, at a viewing distance of 4 dm they do not correspond in directionalization
(40 cm), every 4 mm of displacement is 1A. In this because of the ARC. Eventually, continued train-
case example, 5A would require 20 mm of dis- ing by stimulating the foveas may lead to duality
placement (5A = 20 mm/4 dm). Nasal eccentric fix- of retinal correspondence n which both ARC and
ation would cause the fovea (which sees the brush) normal retinal correspondence (NRC) coexist,
to be directed to the left of the fixation spot. The thus leading to the perception of binocular triplo-
training technique would have the patient look to pia. The ultmate goal, once the intermedate
the right of the shield on the frosted lamp so that stage of binocular triplopia is achieved, s to
the fovea can be protected and the eccentric fixa- strengthen the NRC response so that normal
tion point bleached. fusin can be attained.
10.7.a. Anomalous retinal correspondence should 11.4.C. The centration point, assuming an inter-
be eliminated before binocular training begins so pupillary distance (IPD) of 6 cm (60 mm), is calcu-
that bifoveal fusin can be trained. Reasonably lated by the formula: dioptric distance equals the
good visual acuity is necessary and suppression objective horizontal angle of deviation (angle H)
must be eliminated to achieve bifoveal fusin. at far divided by the IPD in centimeters. In this
Vision training is done under binocular viewing example, 15 divided by 6 equals 2.50 D. Convert-
conditions so that suppression is actively broken. ing dioptric distance into centimeters (100/2.50)
10.8.C. Unharmonious anomalous retinal corre- gives the fixation distance of 40 cm. This s smu-
spondence in the open environment, as with the lating optical infinity with accommodation relaxed,
Bagolini test n this case, puts the patient at risk for and the visual axes cross at this point (i.e., 40 cm
ntractable diplopia following a change in the from the patient). The goal s to have the patient
objective angle of deviation, as by surgery. The fact fixate the penlight n this simulated ortho posture
that cosmesis is not very much compromised s and see a perfect crossing of the afterimages, thus
another reason to let well enough alone and avoid ndicating NRC. A noncross perception would
an operation for this patient. Possibly, reverse indcate ARC. Similarly, the superimposition of an
prisms can be used to mprove cosmesis. Harmoni- X with its crossing at the light would indcate
ous anomalous retinal correspondence tends to NRC, providing the eyes are pointed exactly at the
have a better prognosis for functional cure than do fixation target (the lght). This exactness of pointing
cases of unharmonious anomalous retinal corre- can be verified with the unilateral cover test. A
spondence. Deep suppression can be a blessing movement of the uncovered eye would indcate a
(antidiplopic) if merely a cosmetic cure s sought. remaining angle of anomaly (angle A). The magni-
tude of angle A s represented by the magnitude of
the movement of the uncovered eye taking up fxa-
Chapter 11 tion on the unilateral cover test. The ultmate goal
11.1.a. Constant occlusion between visin ther- in training is for the patient to see an aftermage
apy visits s an mportant first step because it pre- cross and an X of the Bagolin lenses crossing
vents continuance of the ARC, as it does not exist exactly at the lght, wth bifixaton being verfed
(supposedly) under monocular viewing conditions. wth the unilateral cover test. 11.5.e. Exotropc
Intermittent occlusion would probably not be patients can often covary from ARC to NRC when
enough to break the ARC, and ARC would return the eyes go from exotropa to an ortho posture.
whenever there is binocular viewing. Binasal Angles A and H diminish equally as the eyes turn
occlusion is also a good option to keep the patient inward, the result of covariaton. Targets for push-
alternating and prevent amblyopia. 11.2.e. ups along with minus-additon lenses help the
Overcorrection of at east 15A is recom-mended, patient to learn voluntary conver-gence.
but sometimes a greater amount is needed to Afterimages help the patient to monitor the
disrupt the ARC. In this case of esotropa, base-out covaration phenomenon so that NRC can be
of 30A would probably provide suffi-cient achieved with fusional convergence responses.
Overcorrection. ARC is controlled easily once the patent can make
Self-Assessment Test 585
-
^ -
which is a divergence demand, as m Irammg cft
chis eso patient at near. If the separation is 59 deviation.
instead of 67, the 4-mm difference from 63 would
crate a 3A base-out demand. ,
1 3.6.b. The patient with convergence excess nat- 13.12.3. Assuming the ametropia is correctea
urally has more difficulty at near than at far with the most pus /enses, the bifoca/ enses (p/us-
because of the greater eso magnitude at near. The addition lenses) for near can reduce the eso deviation
tromboning closer ncreases the base-in demand, significantly because of the high AC/A ratio. If the
assuming the homologous point separation on the patient has good fusin at far, the chances of
stereogram is the same at far and near. If, for exam- amblyopia and anomalous retinal correspondence
ple, an orthophoric patient views a stereogram at (ARC) are small, therefore improving the prognosis
far with homologous points separated by 87 mm, for cure. Also, near deviations are generally easier to
there is zero demand on vergence. When the same treat successfully than are far deviations for sev-eral
stereogram is tromboned to the near position, reasons, among which are more stereopsis as
there s a base-in demand of approximately 18A "fusional glue" at near, larger retinal images for
([87-631/1.33 = 11). peripheral fusin "glue" at near, and more tactile-
13. 7. o. Jump vergence implies the viewing dis- kinesthetic feedback owing to hands-on activity by
tance is changing from near to far to near, and so the patient as a motivator and patient's mainte-
forth. Step vergence implies a constant viewing nance of attention to the task. 13.13.a. Such sensory
distance but a change in the demand on relative adaptations as ARC and amblyopia must be addressed
vergence with prisms (e.g., flippers). In cases of eso initially. Then, fairly good sensory fusin should be
deviation, the goal of training is to increase base-in established, which is most easily accomplished at
vergence ranges. near. After that, motor fusin ranges can be
13.8.e. The variable Vectograms can move in the increased, more easily at near than at far.
slots of the Dual Polachrome Illuminated Trainer. Eventually, the sensorimotor fusin skills can be
At the fixation distance of 40 cm, each letter repre- transferred to far viewing so that good motor
sents a prism diopter; letters represent base-in fusin ranges can also be achieved for distant
demands; numbers, base-out demands. If the fixa- viewing. 13.14.b. The majority of patients with
tion distance were 80 cm, however, the vergence micro-esotropia have sensory adaptations such as
demand would be 2A base-in. The scale applies amblyopia, ARC, and poor stereopsis. Even in
only to the 40-cm viewing distance. 13.9.>. those cases, there may be rudimentary peripheral
Monocular rock should be adequate before fusin, and patients can develop fairly good motor
binocular rock is given. The patient with fusin ranges, if needed, using peripheral fusin
convergence excess has a high AC/A ratio and is stimuli such as large targets in a stereoscope. The
likely to have difficulty with minus lenses, strabis-mic deviation (manifest) remains, so that,
because the eso deviation increases significantly for example, the esotropa is only 3A, as observed
with responding accommodation to the lenses. with the unilateral cover test (cover-uncover test),
The patient with divergence insufficiency has a whereas the total magnitude measured with prism
low AC/A ratio, and the accommodative vergence and the altrnate cover test may be 10A prism
effect s, therefore, lessened with stimuli of plus diopters or more; the 7A n this example are latent and
and minus lenses. brought out only by continued occlusion dur-ing the
13.10.C/. The double aperture is used in eso altrnate cover test.
cases to crate an orthopic (base-in) effect. 13.1 5.>. The first mportant treatment n esophoria
Because of the dissociative effect that disrupts s to ensure that any significant ametropia is cor-
fusin, the technique s difficult and must be rected with lenses. Fusional divergence training s
learned gradually as the patient learns how to tried next as a conservative mode of visin therapy.
increase fusional divergence ranges. The viewing If lenses and training do not resolve symptoms
distance of the targets (numbered 1 through 12) owing to the esophoric deviation, then base-out
remains at 40 cm.
compensating (relieving) prisms can be tried. Small
angles of esotropa sometimes requre almost total
Self-Assessment Test 587
compensation, but the rule s to be conservative and may be less favorable with training alone in cases of
prescribe only the amoimt necessary (e.g., to neu- constant exotropia. Surgery may be necessary n con-
tralize an angle of fixation disparity [associated pho- stant exotropia with smaller magnitudes as compared
ria of zero with relieving prism]). In many cases, with ntermittent exotropia with larger magnitudes.
however, we find it necessary to prescribe base-out 14.4.C/. The septum s dissociative, with the left
relieving prism before fusional divergence training. visual field being blocked from the right visual field.
This may be the more expedient way to obtain Fusin is difficult under such circumstances, and
patient cooperation, particularly in cases in which great effort is needed to converge and obtain sen-
the Percival criterion is met and comfort is achieved, sory fusin of the dot on one side of the card with
at least temporarily. Vision training, however, is of the dot on the other side. Cutting off the top portion
further benefit to these patients. of the card elimnales this dissociatve effect and
makes easier convergence and fusin of the dots.
Note that movng the far end of the card downward
Chapter 14 often s helpful, because individuis can usually
14.1.e. There are more exo than eso deviations, converge more in down-gaze than straght ahead or
and exo deviations are easier to treat because inter- n up-gaze. This downward maneuver s useful, but
mittency is more common in exo deviations as the effect s not as robust as with cutting off the top
opposed to eso deviations. Intermittent strabismus portion of the card. Another aid for the patient is
means there is fusin at least some of the time; t is having the card moved 3 or 4 cm away from the
easier to ncrease existing fusin than t s to estab- nose so that the convergence demand is reduced.
lish it, as n patients with constant strabismus. 14.5.a. The prism diopter demand on relative
14.2.a. Monocular training is the general rule vergence decreases with increasing distance. The
and the nitial step for most visin therapy patients. demand s half when the distance s doubled. This
Gross convergence training can sometimes elim- s a confidence builder for the patient with a signif-
nate anomalous retinal correspondence, and t sets icantly large exo deviation at far, as in cases of
the stage for the patient having a nearpoint in basic exo or divergence excess. Although t is more
wh'ch sensory and motor fusin can be trained. difficult for such a patient to fuse at far than at
Classic anomalous retinal correspondence therapy near, the mathematic trick of reducing the demand
may be necessary if anomalous retinal correspon- with walk-aways helps the patient to fuse at fart
dence does not covary with normal retinal corre- is hoped, as easily as at near. 14.6.6. The single
spondence. Sensory alignment can be possible f aperture creates a demand for convergence
there s good gross convergence and retinal corre- according to the chiastopic principie. Convergence
spondence. Antisuppression therapy should next demand is a base-out demand. The prismatic
be given. Central sensory and motor fusin can be demand can be calculated by multiply-ing the card
improved. Note that it sometimes may be neces- number by a factor of 2.5, so that card 12 s30 A
sary to include extraocular muscle surgery in the (12x2.5 = 30).
treatment rgimen. This is also true for prescribed 14.7.C. The higher accommodative-convergence/
prisms and other lenses that may be needed ni- accommodation ratios n basic exo and divergence
tial ly. For example, there are some patients who excess patients, relative to convergence insuffi-
require sensory alignment initially with the help of ciency patients, allow great leverage on vergence
base-in prism or minus-lens overcorrection (or demands. When plus lenses are introduced, the
both). Professional judgment s required for such patient has to overeme the ncreased exo deviation
decisions. Finally, good visual efficiency skills by using fusional convergence. This is the reason
should be ensured and home training prescribed binocular accommodative rock s good for vergence
for maintenance. training as well as accommodative training. The low
14.3.e. These numbers are merely general guide- accommodative-convergence/accommodation ratio
lines. Some patients can tolrate much larger exotro- n convergence insufficiency patients does not
pic angles and be asymptomatic after successful allow for much vergence stimuli with the flipper
visin therapy. Constant exotropia, however, more lenses.
likely requires surgery as compared with intermittent 14.8.e. The Pola-Mirror technique allows for mon-
exotropia, because visin training techniques often itoring foveal suppression while creating a conver-
cure ntermittent exotropia, whereas the prognosis gence demand with push-ups in convergence
588 Self-Assessment Test
This glossary is ntended to provide brief defini- ing the center of the fovea; may vary in magnitude or direc-
tions of terms and to clarify some of the abbrevia- tion from moment to moment or day to day and may be
relatively steady or unsteady
tions used n this text. ET Esotropa at far
ET Esotropa at near
First-degree fusin Term used nterchangeably with super-
Abduction Outward horizontal movement of the eye mposition
Abnormal fixation Fixation in which the fovea s not used or Fixation disparity A slght error of vergence in cases of het-
in which the fixation is unsteady erophoria; limit of the magnitude of the angle of fixation
AC/A Accommodative-convergence/accommodation ratio disparty (angle F) considered to be less than 30 minutes
Adduction Inward horizontal movement of the eye Al of are
Afterimage Alpha rhythm Intermittent photic stimulation of Fat fusin Term used interchangeably wth second-degree
7-10 cycles fusin, which is the true fusin but wthout target dispar-
per second Angle/4 Angle of anomaly; in the deviating ties to produce stereopss
eye, the angle Free space Viewing condtions n which the patient s look-
represented by the distance from point a to the center of ing directly at a fixation object that s not housed inside
the fovea Angle E Angle of eccentric fixation; the angle an instrument, such as a stereoscope, or that s not
represented by viewed through any optical system n which the apparent
the distance on the retina from point e to the center of the position of the object is being altered (see True space);
fovea also clinically known as open environment
Angle eta Designation for stereoacuity Angle F Angle of Functional amblyopia Central visual acuity reduction that is
fixation disparity Angle H Horizontal angle of deviation of not attributable to pathologic causes but to functional
the visual axes causes (e.g., anisometropic, strabismic, and hysterical)
measured by objective testing methods Angle K Angle Functional cure In strabismus, determined by meeting the
kappa; the angle subtended by the visual axis criteria of single, clear, comfortable binocular visin at
and the pupillary axis at the nodal point. See Angle lambda all distances from the farpoint to a normal nearpoint of
Angle lambda Angle subtended at the center of the entrance convergence with normal stereoacuity and with no cen-
pupil of the eye by the intersection of the pupillary axis tral suppression; criterion of efficiency possibly also
and the visual axis; inappropriately called angle kappa in included
clinical testing, such testing actually determining angle Graded occlusion See Attenuation
lambda, not angle kappa Angle S Subjective angle of HB Haidinger brushes; entoptic phenomenon used to tag the
directionalization; should be the projected location of the center of the macula
same as angle H if there is normal retinal correspondence Heterophoria A latent deviation of the visual axes from the
but different if there is anomalous retinal correspondence ortho position that requires vergence in order for bifix-
ARC Anomalous retinal correspondence; condition in which ation to be maintained; possible directions of the devia-
the two foveas do not correspond; theoretically, more tion: horizontal, vertical, or torsional
correctly known as anomalous correspondence, as corre- IPD Interpupillary distance; clinically but inappropriately
spondence s cortical rather than retinal Associated phoria called pupillary distance (PD)
Determined by the amount of compensa- KCT Kinetic cover test; a test for estimating angle H by
tory prism needed to reduce angle Fto zero Attenuation means of a moving fixation target and altrnate occlusion
A form of occlusion in which the transmission Maddox cross A graduated vertical and horizontal ruler in the
of light is altered by means of certain filters or lenses form of a cross with a light source placed at the ntersec-
(sometimes called graded occlusion) Bifixation tion for the purpose of subjectively measuring vertical and
Implication of central fusin in which the center of horizontal angles of directionalization; also called Maddox
the fovea of each eye particpales n viewing a fixated object sea I e
Bifoveal test of Cppers Maculomacular test; estmate of Mental effort An attempt by the patient to make vergence
angle A by means of visuoscopy when the patient is see- movements by imagining fixation above or below the
ing under binocular conditons Concomitant Condition horizon or the use of other willful means to produce vol-
in which the measurement of the untary vergence or control other visual functions
angle of deviation is approximately the same magnitude MITT Macula Integrity Tester-Trainer of Bernell, an instru-
in all positions of gaze; clinically most often called ment used to produce the entoptic phenomena of Haid-
comitant Contracture Inability of an extraocular muscle inger brushes; also called MIT
to relax, which MS Maxwell's spot; entoptic phenomena used to tag the pro-
may result in permanent structural changes n which the jected location of the center of the macula
nelasticity becomes irreversible Covariation Negative fusiona! vergence The ability to diverge the visual
Intermittency of anomalous and normal retinal axes behind the object of regard without blurring; stimu-
correspondence in the case of intermittent strabismus, lated by base-in prism
particularly in exotropia. Nonvariable eccentric fixation A condition n which point e
has a fixed site, although fixation may be unsteady as to
DAF Diagnostic action field; six positions of gaze used to eval-
the point used for fixation
ate the action of the six extraocular muscles of each eye
NPC Nearpoint of convergence; single visin with bifixation,
Eccentric fixation Fixation (designated by point e) not employ-
Glossary 591
but not necessarily clear visin, normally expected ideally Stereopsis Term used interchangeably with third-degree
to be approximately 3 cm from the bridge of the nose fusin, whereby binocular depth perception s possible
Open environment See Free space Organic amblyopia Superimposition Term used interchangeably with frst-degree
Central visual acuity loss, attributable to fusin, in which two dissimilar images are localized in the
pathologic causes that are not obvious by means of oph- same direction
thalmoscopy TBI Translid Binocular Interaction Trainer
Pupillary distance See IPD Partial occlusion Occlusion of Third-degree fusin Term used nterchangeably with stere-
less than the full visual field opsis and in reference to stereoacuity
of an eye Past pointing The demonstration of faulty eye- True space Viewing conditions in which the patient is look-
hand local iza- ing directly at a fixation object without intervening optics
tion ability by inaccurately pointing to one side or the that cause reflection or refraction; in clinical usage, possi-
other of a fixated object; commonly found in cases of ble to use filters (e.g., polarizing) and satisfy this defini-
amblyopia with eccentric fixation and in cases of extraoc- tion; see Free space
ular muscle paresis of recent onset PAT Prism Unsteady fixation In central fixation, appearance on visuos-
adaptation test; a prognostic test in cases of copy of point fmoving rapidly in a nystagmoid manner
esotropa to determine whether base-out prism causes around and about the center of the star; in eccentric fixa-
angle Hto increase tion, this rapid movement seen around and about point e
Pathologic diplopia Perception of a doubled image of a fix- during visuoscopy
ated target Physiologic diplopia Perception of a doubled Variable eccentric fixation The condition in which the time-
image of a non- averaged point e changes site from one measurement to
fixated target Point a The place on the retina of the the next on visuoscopy, although fixation may be rela-
deviating eye corre- tively steady at any particular moment; also called wan-
sponding to the fovea of the nondeviating eye Point e derng eccentric fixation
The time-averaged point used for fixation under VER Visual evoked response, visually evoked response;
monocular conditions in eccentric fixation Point i The same as visually evoked cortical potential (VECP) or visu-
center of the fovea of an eye Positive fusiona! vergence The ally evoked potential (VEP)
ability to converge the visual Vergence Disjunctive movement of the eyes
axes in front of the object of regard without blurring; Versin Conjgate movement of the eyes
stimulated by base-out prism Secondary angle of Visual axis The line of sight that extends from the fixated tar-
deviation The measured angle of devia- get through the nodal point to the center of the fovea
tion found with the paretic eye fixating Second-degree Wandering eccentric fixation See Variable eccentric fixation
fusin Term used nterchangeably with fat XT Exotropia at far
fusin Steady fixation The condition determined on XT1 Exotropia at near
visuoscopy in Zero point (point zero) The point on the retina of the strabis-
which the point on the retina used for fixation (either for mic eye representing no vergence demand; in the case of
e) appears relatively stationary as the patient fixates the bifixation, point zero is the same as point f, the center of
nonmoving target of a visuoscopic instrument the fovea; synonymous with target point
Index 595
Note: Page numbers followed by f refer to figures; page numbers followed by f refer to tables.
Amblyopia therapy (contnued) Amsler grid testing, 164 Anaglyphic adaptation theory of, 174, 324
Haidinger brush training for, 301, fusin games, 379-380 Anesthesia, amblyopia therapy and, 309-310
301 f, 302-304, 302f Hart anticholinesterase interac- angle of deviation and, 172, 1 73f
Chart for, 298-299, 299f tion with, 219 classification of, 167-170,167f, 168f,
monocular telescope for, 300 Angle kappa, 105-106, 106f 169f, 170f, 171f, 172t depth
readingfor, 299 resolution Aniseikonia, 22, 452-455, 453f, 454t of, 1 75-1 76 etiology of, 1 74-1 75
techniques for, 297-300, Anisometropia case study of, 364-365, exotropia and, 340-341 harmonious,
299f 365t reading performance and, 22 168, 168f, 171f, 324 horopterin,
small object counting for, 299 Anisometropic amblyopia, 144-145, 170, 172, 173f horror fusionis, 172,
swinging ball training for, 295-296, 313-320 173f, 174 motor theory of, 1 74-1 75,
296f case studies of, 313-320 Ann 324-325 paradoxical, 169, 170f,
tachistoscopic training for, 300 Arbor (Michigan) Tracking 171f postoperative, 341-342
throwing and hitting games for, in monocular fixation training, 296- prevalence of, 176 remediation of, 1
294, 295f 297, 298f 75 Swann split-field effect in, 1 72, 1
tracing and drawing for, 294 in saccadic eye movements, 529, 530f 74f,
tracking with auditory feedback for, Annulus of Zinn, 5 Anomalous 185 testing for,
296, 297f correspondence therapy, 176-185
video game tracking for, 294-295 323-345 afterimages testing in, 176-179,
visual tracing for, 296, 298f binasal occlusion in, 325-326, 326f 1 77f, 1 78f, 1 79f Bagolini
occlusion in, 281-287 amblyopia binocular triplopia in, 330 case striated lens test in, 183-
prevention in, 283-284, management n, 342-343 case 185, 184f Brock-Civner
284t studies of, 343-345 constant total transfer test in, 179,
compliance with, 285 direct, 281- occlusion in, 325 contraindications 180f
283, 282f, 282t, 283f duration of, to, 323-324 with exotropia, 340-341 color fusin test in, 185 Cppers'
286 efficacy of, 286-287 inverse, graded occlusion in, 326 major bifoveal test in, 179-182,
281, 283-284, 284t motivation in, amblyoscope techniques n, 181f, 182f
285 occluder types for, 284-285, 328-336, 329t altrnate dissociated red lens test n, 176
284t partial, 281 fixation for, 331 entoptic tags for, Haidinger brush test for, 179, 180f
prism therapy and, 291-292, 292f 332-333, 333f flashing targets at Hering-Bielschowsky test n, 176-
progress with, 285-286 red-filter objective angle 1 79, 1 77f, 1 78f, 1 79f major
and, 291 short-term, 292-293 for, 329-331, 330f Flom amblyoscope in, 182-183 therapy
total, 281 swing technique for, 333-336, for. See Anomalous corre-
visin training with, 287 penalizaron 334f, 334t, 335f, 344-345 spondence therapy unharmonious,
in, 287-291 efficacy of, 290-291 macular massage for, 331 open 168-169, 1 69f, 1 70f,
farpoint, 288-289, 288f space training with, 333 vertical 171f, 324
management of, 289-290, 290t near, displacement of targets for, Anticholinesterase drugs, 219
288, 288f optical, 289, 289f total, 331 Antisuppression therapy, 310-312, 311f,
288, 288f without spectacles, 287 occlusion procedures n, 325-326 347-365, 354t attention and,
pleoptics in, 305-309 Bangerter's open environment techniques for, 349 auditory sense and, 351-352
method of, 306 Cppers' method of, 336-340, 336t afterimages brightness and, 349, 350f Brock
306-307, at centration point n, string and beads in, 359-361,
307f, 308-309, 309f 337, 338f Bagolini lens 360f, 361 f
efficacy of, 307-308 Vodnoy technique in, 339- case studies of, 364-365, 365t
afterimage method of, 308, 340, 339f binocular luster cheiroscopic coloring n, 358
308f training in, 336- cheiroscopic counting n, 358
progress in, 312-313, 313f red-filter 337 Haidinger brush cheiroscopic drawing n, 351, 352f,
in, 291 refractive error management technique in, 338- 358
in, 280- 339 prism-rack afterimage cheiroscopic games n, 357-359, 359f
281 technique in, cheiroscopic point-to-point chasing
sequence of, 280t, 540 suppression 338 optical procedures in, n, 358
and, 310-312, 311f Amblyoscopes, 327-328, cheiroscopic tracing in, 358-359
141-143, 142f, 143f. See a/so Major 327f color and, 349-350 combination
amblyoscope Amblyoscopic precautions with, 323-324 prism techniques in, 352-353 four-step
convergence technique, 407 overcorrection in, 327-328, approach to, 353-354, 353t hand-
327f rockum sockum mirror superimposition n, 357,
optical procedure 357f intermittent stimuli
n, 328 and, 350-351,
Anomalous retinal correspondence, 350f
166-185
Index 597
kinesthetic senses and, 351 major Bernell's three-figure test, 141 pharmacologic, 204-205
amblyoscope n, 355-356 chasing Bielschowsky head-tilttest, 239-240 philosophies of, 263-268 of Javal
for, 355-356 endpoint suppression Bifoveal test of Cppers, 179-182, and French school, 263-
for, 356 flashing for, 355 illumination 181f, 182f 265, 264f, 265t
gradicntfor, 355 management Binasal occiusion, in anomalous cor- optometric, 265f, 265t, 267-268
considerations n, 363- respondence therapy, of Worth and English school, 265f,
364 325-326, 326f Binocular 2645t, 2765-267
modified Remy Separator n, 359 accommodative rock, 386, principies of, 268-276
occiusion, 348 416-417 prisms n, 200
penlight and filters in, 356-357, 356t Binocular luster training, 336-337 retainer home training in, 276
Pola-Mirror in, 362, 363f reading Binocular triplopia, 330 Binocular sequence of, 268-270, 269t sliding
bars in, 362-363 tactile senses and, visin, 3-17. See a/so Visual vergence training in, 270t,
351, 352f target contrast and, 349 skills efficiency 271
target movement and, 351 target size accommodation and, 6, 7f step vergence training in, 270t, 271
and, 350, 350f televisin trainers in, advantages of, 3-5, 4f, 5t conjgate tromboning vergence training in,
361-362, 362f translid binocular gaze movements and, 6- 270t, 271 vergence training
interaction trainer 8, 8f, 9f methods in, 270-
in, 354-355, 355f variables n, deficiencies of, 5 273, 270t
349-352, 349t, 350f Aperture-Rule extraocular muscles and, 5-6, 6f, 7f visin training in, 201 Bioengineering
Trainer eye movements and, 6-10, 7f, 8f, 9f, model, of accommodation and
in esotropa, 387-388, 387f, 492- 10f motor component of, 3, vergence, 97-99, 98f Biopter
493, 493f n exotropia, 412, 5-10, 6f, 7f, stereogram, 377, 379f Blindness,
412f, 41 3f, 512- 8f, 9f, 10f saccadic, 23 Blowin fracture, 248
514, 513f neural summation in, 16 ocular Blowout fracture, 247-248 Blur,
Associated phoria criterion, 85, 87, 91 dominance and, 16 Panum's fusin intermittent, 21, 41 Botulinum toxin
Asthenopia, 21 Atropine reas and, 11 physiologic diplopia injection,
in penalization, 287, 289, 290t side screening for, 205-206
effects of, 289, 290t Attention, in 12-13 Brainstem lesions, 250 Brewster
antisuppression therapy, retinal correspondence and, 11-12 stereoscope in antisuppression therapy,
349 Auditory biofeedback, in sensory component of, 3, 10-16, 12f, 311 in esotropa, 375-379, 376f,
congenital nys- 13f, 14, 15f, 16f sensory 499-
tagmus, 441, 442f fusin and, 13-16, 14f, 15f, 500, 499f in exotropia, 410
Auditory sense, in antisuppression ther- 16f sometric vergences with, 377 step
apy, 351-352 singleness horopter and, 11-12, 12f vergences with, 377, 378f tromboning
stereopsis and, 14-15, 15f, 63-64, with, 377-379 Brightness, in
64f antisuppression therapy,
Bagolini lens technique, in anomalous theories of, 15-16, 16f three- 349, 350f
correspondence therapy, 339-340, dimensional model of, 86f-87f Brock string and beads in
339f Bagolini striated lens test, 183- vergence and, 8-10, 10f Binocular antisuppression therapy, 359-361,
185, visin therapy, 199-206, 200f, 360f, 361 f
184f, 231 263-276. 5ee a/so Esotropa, in esotropa, 380, 498-499, 498f
Bailey-Lovie chart testing, 151, 151f visin therapy for; Exotropia, in exotropia, 409, 509-511, 51 Of
Bangerter's method, 306 Bar reading in visin therapy for Brock-Givner afterimages transfer test,
antisuppression therapy, 311-312, adjustable suture procedure n, 203 179, 180f
311f, 362-363 botulinum toxin in, 205-206 Brown syndrome, 246-247
in exotropia, 418, 523-525, 524f with defintion of, 268 extraocular Brckner test, 110, 110f
prism rock, 386 Basic central fixation muscle surgery in, 201-
training, 302 Behavior, maladaptive, 21 204, 201 f C
Bernell fixation disparity test, 81, 81 f, home training for, 272-273 Cantonnet, A., 264-265 Centration-
90 Bernell Macular Integrity instrument trainng for, 273 sometric point training, 369-370 Chasing, with
Tester-Trainer, vergence traning n, 272 jump major amblyoscope,
161-163, 162f Bernell Mirror vergence training in, 270t, 355-356
Stereoscope n esotropa, 374-375, 271-272 lenses for, 199 Chavasse, F. B., 266-267, 268
375f, 490^91, mental effort in, 265 monitoring of, Cheiroscopic games, 357-359, 359f
490f in 275-276 occiusion in, 200-201 coloring, 358
exotropia, 408-409 office training for, 272-273 open- counting, 358
environment training for, 273 patient drawing, 351,352f, 358
motivation n, 273-275, 274t, point-to-point chasng, 358
275t tracing, 358-359
598 Index
Chiastopic fusin, 414-416, 414f, 415f, refractive error correction in, 401 sixth, lesions of, 239
416f, 417f, 519-522, 520f sensory and motor fusin training in, thrd
Chronic progressive externa! ophthal- 403-404 in Duane retraction syndrome,
moplegia, 244-245 Clinical sensory anomalies n, 401 simulated 245
wisdom criterion, 77, 90-91, divergence excess and, lesons of, 240-242, 240t
90t Cogan's nternuclear 226-227 Crowding phenomenon, in Snellen chart
ophthalmoplegia, surgery in, 404^05, 404t, 405t testing, 150 Cppers' bifoveal
249 variability in, 227 test, 179-182, 181f,
Cogwheel pursuits, 250 Color, in visin therapy n, 227, 400^05, 400t. 182f Cppers' pleoptcs, 306-
antisuppression therapy, 349- See a/so Exotropia, visin ther- 307, 307f, 308-
350 apy for 309, 309f
Color fusin, 13, 50, 185, 336-337 Comitant vertical deviations, 232-233 Cyclophoria, visin therapy in, 468
Color visin testing, 165 Comitancy, Computerized convergence training, Cyclovertcal deviations, 232-233. See
110-126 causes of, 110-111, 1111 418-419 Computerized a/so Strabismus
criteriafor, 111-112, 112f, 113f divergence techniques, comitant, 232-233
deviations and, 112-113, 114f, 118- 390-391 Computerized visin dissociated, 222, 222f, 233
121, 120f duction testing for, therapy, 390-391, Cyst, iris, 219
113-115, 114t, 470 Confirmation procedure,
115t for prism pre- D
forced duction test for, 115 Hess- scription, 91-92 Confusin, Dalrymple's sign, 243 Demand line,
Lancaster test for, 123-126, 123f, 137 Congenital esotropa. See 69, 70f Developmental Eye
124f, 125f, 126f recording Infantile Movement Test,
protocol for, 118-121, esotropa 31-33, 32f, 33f
120f Conjgate gaze movements, 6-8, 8f, Developmental history, 551-553
saccadic velocities test for, 114 9f. See a/so Pursut eye movements; in Strabismus, 104-105
single-object method for, 122-123 Saccadic eye movements Connect- Diisopropylfluorophosphate in high
spatial localizaron testing and, 121 the-dot books, in monocular AC/A accommodative esotropa, 219-
subjective testing for, 122-126, 123f, fixation trainng, 294 220 in penalization, 287 Diplopia
124f, 125f, 126f Consecutive Strabismus, 234 in Graves' disease, 243
terminology for, 111-112, 112f, 113f Constan! total occlusion, 325 heteronymous, 12, 13f, 122
three-step method for, 115-118, 116t, Contact lenses homonymous, 12, 12f, 122
11 7f, 118f, 119f two-object n accommodative esotropa, 217 n ntractable, 435-438, 437t, 448 case
method for, 123-126, 123f, amblyopia therapy, 281 in high AC/A study of, 448 diagnosis of, 435-436
124f, 125f, 126f accommodative esotropa, 218 hypnotherapy in, 437-438 occlusion
versin testing for, 113f, 114t, 115 Continuous motion training, 528-529, in, 436-437 prism displacement in,
Comitant esotropa. See a/so Strabismus 52 8f, 52 9f 437 noncomitancy and, 121, 127
centration-pointtraining in, 368-370 Contrast sensitivity, 4 after orbital fracture, 248 pathologic,
changing viewing distance in, 371- Convergence. See a/so Vergence 13, 14, 14f physiologic, 12-13, 12f,
372 absolute, 49-52, 50f, 50t gross, 75 14, 23f heteronymous (crossed), 12,
follow-up care for, 372 Maddox classification of, 49 13f homonymous (uncrossed), 12,
plus-lens additions n, 368 nearpointof, 49-52, 50f, 50t relatve, 12f single-object method testing for,
primary, 224-225, 224t 52-54, 53t, 54t, 55t terminologic use 122-
prisms in, 368 of, 52 Convergence excess esophoria, 123 suppression of, 135-
refractive error correction n, 368 95-96, 143. See a/so
sensory and motor fusin training in, 95f Suppression
370-371,3711 surgery in, Convergence excess esotropa, 391-393 Dissociated red lens test, 176
372 visin therapy n, 368-373, Convergence fatigue, 76 Convergence Dissociated vertical deviation, 222, 222f,
368t. nsufficiency exophoria, 233
See a/so Esotropa, visin 93, 93f, 423-427, 426f Divergence, 10. See a/so Vergence
therapy for Convergence training at near, 411, 514- Divergence excess exophoria, 94, 94f,
Comitant exotropia. See a/so Strabismus 517, 515f 419-421 Divergence
diagnosis of, 226-227 follow-up care Convergence walk-aways, 411 insufficiency esophoria,
in, 405 gross convergence training Cosmesis, in strabsmus, 133-134, 134t, 94-95, 95f Divergence
n, 401- 197-198, 198f Counting insufficiency esotropa,
402 small objects, 299 Cover-uncover test, 395-396
intermittent nature of, 226 107-108, 108f Cranial nerve Doll's-head maneuver, 7, 221
lenses in, 402-403 onset of, fourth, lesions of, 239-240, 240f Dominancy, eye, 16, 133
226 primary, 225-227, 226t
prisms in, 402-403
Index 599
Dorsal midbrain syndrome, 250-251, Aperture-RuleTrainer in, 387-388, Exotropia, 102-103. See a I so
251t 387f, 492-494, 493f n basic Strabismus anomalous
Double elevator palsy, 241-242 esotropa, 391-395 Bernell Mrror retinal correspondence
Double Maddox torsin training, in Stereoscopebase- and, 340-341 basic, 421-423
acquired noncomitant devi- n training in, 374-375, 375f, classification of, 400 comitant. See
ation, 434 490-491, 490f binocular Comitant exotropia gross
Doubling, intermittent, 21 Downbeat accommodative rock in, convergence training in, 340-
nystagmus, 257t-258t Dual 386 Brewster Stereoscope in, 341
Polachrome Illuminated Trainer, 375-379, surgery in, 404-405, 405t visin
381, 381 f, 491^92, 492f 376f, 378, 379f, 499-500, therapy for, 399-427, 400t,
Duane cover test, 108-109, 109f, 109t 499f Brock string and 541-542. See a/so Binocular
Duane retraction syndrome, 37, 245- beadsbase-in visin therapy; Strabismus,
246, 246f, 444-446, 445f training n, 380, 498-499, prognosis for
Ductions, 113-115, 114t, 115t Dvorine 498f Allbee Card in, 409-410, 409f
stereogram, 377, 378f Dyslexia. See case studies of, 391-398 amblyopia treatment in, 401
a/so Reading policy statement on, 549- centration-point training in, 369- amblyoscopic convergence tech-
550 370 nique in, 407 anomalous
compensating prisms n, 369 retinal correspondence
computerized divergence tech- treatment in, 401 Aperture-
Eccentric fixation, 159, 160 in niques in, 390-391 n Rule Trainer in, 412,
amblyopia, 147 Hering- convergence excess esotropa, 412f, 413f, 512-514, 513f
Bielschowsky test and, 178, 391-393 bar reader with prisms in, 418,
179f in divergence insufficiency esotro- 523-525, 524f n basic
strabismic amblyopia and, 144 pa, 395-396 flipper prisms in, exotropia, 421-423 Bernell Mirror
Echothiophate iodide in high AC/A 384, 384f, 386, Stereoscope in,
accommodative esotropa, 219-220 in 502-503, 502f lens additions 408-409 binocular
penalizaron, 287 Edrophonium in, 369 n mcroesotropia, 396- accommodative rock in,
chloride (Tensilon) test, 397 orthopc fusin n, 389-390, 416-417
242 389f, Brewster Stereoscope in, 410
Electromyography, 245 390f, 494-496, 495f Brock string and beads technique
Electroretinography, 165 Endpoint peripheral fusin rings n, 380- in, 409, 509-511, 51 Of case
suppression, 356 Entoptic tags, 381, 381 f, 500-502, 501 f studies of, 419-427 chiastopic
332-333, 333f Equipment refractivo error correction in, 368 fusin n, 414-416,
suppliers, 562-565 Esophoria Remy Separator in, 388-389, 388f, 414f, 41 5f, 41 6f, 41 7f, 519-
basic, 95, 95f 389f, 496^97 sensory and 522, 520f
convergence excess, 95-96, 95f motor fusin training compensating prisms n,
divergente insufficiency, 94-95, 95f n, 370-371,3711 sensory 402-403
visin therapy for, 373, 373t, 541. anomaly elimination in, computerized convergence train-
See a/so Esotropa, visin 368-369 ing in, 418-419 n convergence
therapy for sequence of, 540-541 surgery insufficiency exo-
case study of, 397-398 sequence of, and, 372-373, 372t televisin phoria, 423^27, 426f
541 Esotropa. See a/so Strabismus trainer in, 502-503, convergence training at near n,
accommodative. See Accommoda- 503f Tranaglyphs in, 381f, 411, 514-517, 515f
tive esotropa acquired, 102, 103t 383, 491- convergence walk-aways n, 411,
basic, 391-395 classficaton of, 368 492 Vectograms n, 381- 517-518, 517f n
comitant. See Comtant esotropa 386, 382f, divergence excess exotropia,
infantile. See Infantile esotropa prisrn 385f, 491-492, 492f 419-421
overcorrection n, 343-344 visin vergence rock techniques n, 384f, follow-up care in, 405 framing
therapy for, 367-398, 368t, 540- 386 with prisms in, 55, 418 gross
541. See a/so Binocular visin viewing distance in, 371-372 convergence training in,
therapy; Strabsmus, prognosis for Euthyscope, 306-307, 307f 401-402
amblyoscopic divergence tech- Exophoria sometric vergence training in, 410
nique in, 374 accommodation with, 45 basic, 93- lens additions in, 402^03 pencil
anaglyphc fusin games n, 379- 94, 94f convergence insufficiency, push-aways n, 412-414,
380 93, 93f divergence excess, 94, 94f 507-509 pencil push-ups
presbyopic, 93 reading performance in, 412^-14,
and, 22 visin therapy n, 405- 507-509, 508f
406, 406t, peripheral fusin rings in, 408
542 Pola-Mirror vergence techniques n,
Exophthalmos, 243 418
600 Index
Exotropia (continuad) Fixaton disparity, 78-87 definition of, Graves' ophthalmopathy, 243-244,
projected base-out si des in, 411- 78-79, 79f measurement of, 79-85 244t Gross convergence
412,518-519 Bernell testfor, 81, 81 f, 90 graphical training, 340-341,
refractive error correction in, 401 plotof, 84-85, 85f MallettUnitfor, 401^02
sensory and motor fusin training 83-84,90 Saladin Near Point
in, 403-404 sequence of, Balance Card H
400-405, 400t, 541- for, 79, 80f, 81, 84, 90 Haidinger brush
542 Sheedy Disparometer for, 84, 90 in anomalous correspondence ther-
step vergence training in, 410 validity of, 89-90, 89t apy, 338-339 in monocular fixation
stereoscope tromboning n, 410 Vectographic Slide for, 81, 82f training, 300-
televisin trainer in, 41 7-418, Wesson Card for, 79, 81, 81 f, 84, 305, 301 f, 302f Haidinger
522-523 three-dot card in, 90 prisms for, 82-83, 83f, brush testing, 161-163, 162f,
409-410, 409f, 85, 87, 90- 1 79, 180f
41 Of, 511-512 92, 90t Hand-mirror superimposition, 357, 357f
Tranaglyphs in, 410-412, 51 7-519 three-dimensional model of, 86f-87f Haplopic (singleness) horopter, 11-12,
Vectograms in, 410-412, 517-519, Fixation disparity curve, 84-85, 85f, 12f Hart Charts, 298-299,
51 7f vergence rock 89-90 299f, 533-537,
techniques in, 417- Fixation training, 293-300, 293t. See a/so 534f-536f
418, 522-525, 524f voluntary Amblyopia therapy, monocular fixation Head posture
convergence technique training n for saccades, 527-528 in neurogenic strabismus, 238
in, 407, 506-507, 507d Flashing, with major amblyoscope, 355 noncomitancy and, 121-122, 122t in
Extraocular muscles, 5-6, 6f, 7f Flashing targets at objective angle, strabismus, 121-122,229 Headache,
surgery on, 201-204. See a/so Surgery 329-331, 330f 21
Eye movements pursuit, 8, 9f, 35-38. Flashlightchase, 532-533 Fat fusin, Head-tilt test of Bielschowsky, 239-240
See a/so Pursuit 14 Flipper prisms, 384, 384f, 386, Heinsen-Schrock system n pursuit
eye movements saccadic, 7, 502- movement testing, 36-37,
8f, 9f, 22-35. See a/so 503, 502f Flom swing 36t in saccadic eye
Saccadic eye movements vergence, technique, 333-336, 334f, movement testing,
8-10, 10f. See a/so Vergence 334t, 335f, 344-345 Fly 24-25, 25t, 34t Hering-
vestbulo-ocular, 7-8, 39-40, 221 Eye- stereopsis test, 60f Forced duction test, Bielschowsky test, 176-179,
hand coordinaron techniques, in 115 Four base-out prism test, 109- 1 77f, 1 78f, 1 79f Hering'slaw,
monocular fixation training, 294- 110, 7, 9f, 111, 111t Hess-Lancaster
297, 295f, 296f, 297f, 298f 110f Fourth cranial nerve testing, 123-126, 123f,
palsy, 239-240, 124f, 125f, 126f
240f Heteronymous diplopia, 12, 13f, 122
Falling eye sign, 240, 240f Farnsworth Foveal localization, 303-304 Foveal Heterophoria. See a/so Heterophoria
test, 165 Farpoint penalizaron, 288- tag techniques, 300-305, 301 f, case analysis farpoint, 70
289, 288f Fast pointing (foveal 302f, 305f Fracture blowin, nearpoint, 70 therapy for, 198-199,
localization), 248 blowout, 247-248 Framing 199t, 466-467,
303-304 with prisms, 418, 525 Fresnel 467f
Field of visin, 4, 4f Five-dot card test, prisms, 92 Frisby test, 62f Heterophoria case analysis, 69-99
25-26, 27f Fixation, 38-40, 39f. See Frontal cortex, lesions of, 249-250 accommodative convergence/accom-
a/so Fixation Fusional supplementary convergence modation ratio and, 70-72, 71t
disparity valu, 56 associated phoria criterion in, 91
bifoveal, loss of, 104 classification Fusional vergence, 9 at far basic esophoria in, 95, 95f basic
of, 160, 160t eccentric, 159, 160 in (negative), 52-53, 53t, 54t at exophoria in, 93-94, 94f
amblyopia, 147 Hering-Bielschowsky near (positive), 53-54, 55t bioengineering model of, 97-99, 98f
test and, 178, clinical wisdom criterion in, 77, 90-
179f 91
strabismic amblyopia and, 144 Gaze paretic nystagmus, 257t-258t convergence excess in, 95-96, 95t
evaluation of, 38-39, 40t, 159-163 Generalized fibrosis syndrome, 247 convergency insufficiency in, 93, 93f
Haidinger brush testing in, 161- Glossary, 590-591 Graded occlusion divergence excess n, 94, 94f
163, 162f method of Revell, divergence insufficiency in, 94-95,
visuoscopy in, 160-161, 161f, 162f 326 Gradient accommodative- 95f
Southern California College of Optom- convergence/ fixation disparity analysis n, 78-87
etry 4+ test of, 38-39, 40t accommodation ratio, 72, 73f definition of, 78-79, 79f
unsteadiness of, 38, 159, 160, 160t instruments for, 79-85, 80f, 81 f,
vestbulo-ocular reflexes and, 39^1-0 82f, 83f, 85f, 86f, 87f prism
prescription and, 85, 87
Index 601
Horror fusionis, 172, 173f, 174, 196, King-Devick test, 30-31, 31f, 31t, 34t
gradient accommodative conver-
324 Howard-Dolman Knapp procedure, 242 Krimskytest,
gence/accommodation ratio and, 72
pegtest, 59-60, 62, 107
lens and prism prescription criteria
and, 76-78, 90-92 Morgan's 62t
expected criterion in, 77 Morgan's Hyperaccommodation, 44-45, 45t
Hyperopia, reading performance and, 22 Lang test, 62f
normativa analysis in, 76, Lateral adherence syndrome, 247
76t Hyperphoria
reading performance and, 22 visin Laterality, eye, 132-133,1321 Learning,
normal zone with symptoms in, 96-97 visin and, policy statement
Percival's criterion in, 78, 91 prism therapy n, 446-447, 446f, 467-
468, 468f, 543 on, 549-550
confirmation procedure in,
Hyperthyroidism, 243-244, 244t Lens rock, 465-466, 537-538, 537f
91-92
Hypnotherapy, 437^38 Lenses
teV\ab\V\\v( oi, 88
in accommodative esotropa, 216-
tesVcNcXeA xotxe cases w\, %, %\
Sheard's criterion in, 77-78, 91 \ l\7,TYtt
i
SYveedy's cnteon \v\, 9 A tonic Idntica! visual direction horopter, "\ \ in amb\yop\atY\etap y, 1^-lftA m
convergence and, 70, 711 validityof, \\\um\r\a\\o'n ^ad\evM, \w\th vcu\ov com\Xantexo\ro9\a, 401-403 in
87-90,891 vergence anomalies in, amblyoscope, 355 esotropa, 369 in exotropia, 402^1-03
92-97, 93f, Image degradation amblyopia, 145, 145t n high AC/A accommodative esotro-
94f, 95f, 96f zone of clear, Inertia of accommodation, 45 Infantile pa, 218, 218f
single binocular visin esotropa, 220-225, 220f. See n nfantile esotropa, 222-223 n
and, 72-76, 73f, 74f, 75f a/so Strabismus amblyopia in, microtropia, 232 prescription for,
Hirschbergtest, 106-107, 107f 221 crossed fixation n, 220-221 76-78. See a/so
Hofstetter formula, 42 Home visin dissociated vertical deviation in, 222, Prism prescription in
training, 272-273, 276 with Ann Arbor 222f strabismus, 199 for visual skills
(Michigan) Tracking, doll's-head maneuver in, 221 efficiency, 464^65 Levodopa, n
529 essential, 102, 103t inferior oblique amblyopia therapy, 291 Linear
with Aperture-RuleTrainer, 494, 514 muscle overaction displacement test, for stereoacuity,
with Bernell Mirror Stereoscope, 491 in, 221-222, 221f nystagmus in, 59-60, 62-63, 621, 63t Ludlam's
with Brewster Stereoscope, 500 with 222 optical treatment in, 222-223 rockum sockum method, in
Brock string and beads, 499, refractive errors in, 220 spontaneous anomalous correspondence therapy,
510-511 with chiastopic resolution of, 222 surgery in, 223-224, 328, 337
fusin technique, 224f visin training n, 223 Infantile
521, 522 noncomitant deviation, 429- M Macular Integrity
with convergence at near, 516-517 430 Tester-Trainer, 300-
with convergence walk-aways, 517- diagnosis of, 429 management of, 305, 301 f, 302f Macular
518 429^130, 430t Infantile nystagmus, massage, 331 Maddox, E., 267 Maddox
with flashlight chase, 533 with Hart 253-255, 254t Interferometry, 159, rod test, 129, 130f Major
Chart, 533, 537 with lens rock, 538 160f Intermittent photic stimulation, 440- amblyoscope, 141-143, 142f,
with Marsden ball, 532 vs. office 441, 143f, 182-183 anomalous
training, 272-273 with orthopic 440f Internuclear correspondence therapy
fusin, 496 with pencil push-aways ophthalmoplegia, 248-249, with, 328-336, 329t altrnate
and push- 248t Infraocular pressure, in fixation for, 331 entoptic tags for,
ups, 498, 509 Graves' disease, 332-333, 333f flash ng targets at
with peripheral fusin rings, 501-502 243-244 objective anf^e
for regression monitoring, 276, 276t Iris, miotic-related cysts of, 219 for, 329-331,330f Flom swing
with Remy Separator, 497 with Isoametropic amblyopia, 145 technique for, 333336^
sequential fixator, 531 with standing Isometric vergence training, 410 334f, 334t, 335f, 344-345
rotator for pursuits, 531 with televisin macular massage for, 331
trainers, 503 with three-dot card, 512 J open space training with, 333
with Tranaglyphs, 492, 517-518, 519 Javal, L. E., 263-265, 264f vertical displacement of I
with Vectograms, 517-518, 519 with Jump focus, 465 Jump 331 anomalous
vergence rock, 523, 524-525 with vergence training, 270t, 271- retinal
voluntary convergence, 506- 272 testingwith, 182-1CI
507 antisuppression therapy wM^J
Homonymous diplopia, 12, 12f, 122 K chasingfor, 355-356 endpoint
Horopter, 11-12 KeystoneTest 1, 58 suppresson ( flashingfor, 355
in anomalous retinal correspondence, Kinesthetic sense, n antisuppression illumination gradient i Mallet
1 70, 172, 1 73f therapy, 351 fixation disparity test4
602 Index
Maples oculomotor test, 33-34 Myogenic palsy, 242-245 surgery in, 441-443 visin
Marsden ball, 295-296, 296f, n chronic progressive external oph- training in, 439-441,
531-532 Medial longitudinal thalmoplegia, 244-245 440f
fasciculus, lesions in hyperthyroidism, 243-244, 244t in infantile esotropa, 222 latent, 256t,
of, 248-249, 248t MEM in myasthenia gravis, 242-243, 242t 259 physiologic, 252-253, 253t rare
retinoscopy, 43-44, 44f, 44t, 45, Myopia types of, 257t-258t, 259 vestibular,
45t night, 45 256t voluntary, 253, 253t Nystagmus
Mental effort, in strabismus therapy, 265 reading performance and, 22 blockage syndrome, 255-256,259
Meridional amblyopia, 145 Meta-
analysis, of reading performance N O
studies, 22 Near penalization, 288, 288f Obi que muscles, 5-6, 6f, 7f
Metamorphopsia, 436 Microtropia, Neurogenic palsy, 238-242 vs. Occipital lobe, lesions of, 250
229-232. See a/so Strabismus developmental strabismus, 238, Occluders, 282f, 284-285, 284t
altrnate cover test n, 230, 230f 238t Occlusion, 200-201
Bagolini striated lens test in, 231 etiology of, 238, 238t of fourth n acquired noncomitant deviation,
management of, 231-232, 396-397 cranial nerve, 239-240, 240f head 430-431, 431f
primary, 230 secondary, 230 posture in, 238 of Mbius syndrome, in amblyopia therapy, 281-287, 282f,
unilateral neutralization test n, 230t, 239 of sixth cranial nerve, 239 of 282t, 283f, 284t. See a/so
231,231f third cranial nerve, 240-242, Amblyopia therapy, occlusion
visuoscopy in, 231 240t, 447-448 in
Miotics Neutral-density filter testing, 164-165 in anomalous correspondence ther-
in accommodative esotropa, 217 n Night myopia, 45 apy, 325-326, 326f in antisuppression
high AC/A accommodative esotropa, Noncomitant deviation, 110, 111, therapy, 348 in intractable diplopia,
219-220 in penalization, 287 side 113f. See a/so Comitancy; 436-437 Occupation
effects of, 219 toxicity of, 219 Mirror Strabismus binocularity and, 4-5, 5t intermittent
Stereoscope. See Bernell Mirror acquired, 430-435, 431f, 432f, 433f blur and, 41 Ocular calisthenics, 433
Stereoscope diagnosis of, 430 double Maddox Ocular dominance, 16, 133 Ocular
Misdirection syndrome, 240 Mbius torsin training in, myopathy of von Graefe, 244-
syndrome, 239 Monocular estmate 434 245
method retinoscopy, 43-44, 44f, 44t, follow-up for, 435 fusin field Oculogyric crisis, 251
45, 45t Monocular fixaton tranng, expansin in, 434 occlusion n, Oculomotor nerve
293-300, 293t. See a/so Amblyopia 430-431, 431 f ocular calisthenics in Duane retraction syndrome, 245
therapy, monocular fixation train-ing in in, 433 prism compensation in, lesions of, 240-242, 240t, 447-448
Monocular telescope, 300 Monocular 432-433, Open environment techniques, 336-
visin, 11 Monovision, 455 Morgan, 432f, 433f sensory and 340, 336t afterimages at
Meredith W., 267, 267f Morgan's motor fusin training centration point in,
expected criterion, 77 Morgan's in, 433-434 surgery in, 434435 337, 338f Bagolini lens
normative analysis, 76, 76t Motivation diplopia and, 121 head posture and, technique in, 339-340,
in amblyopia therapy, 285 121-122, 122t infantile, 429-430 339f
in binocular visin therapy, 273- diagnosis of, 429 management of, binocular luster training in, 336-337
275, 274t, 275t Motor 429-430, 430t Noncomitant Haidinger brush technique in, 338-
fusin, 370-371, 371t Motor fusin intermittent hypertropia, 339 prism-rack afterimage
training. See Sensory and 446-447, 446f technique in,
motor fusin training Motor theory, of Nott dynamic retinoscopy, 43, 43f Nuil 338 Open space training, with
anomalous retinal cor-respondence, 1 regin, 254 Nystagmus, 252-259 major amblyo-
74-1 75, 324-325 acquired, 443-444 congenital, 253- scope, 333 Ophthalmography,
Mltiple sclerosis abducens nerve 255, 254t, 438-443, 25-27, 26f, 27f, 28f,
lesin n, 239 internuclear 43 9f, 440f afterimage tag 29f
ophthalmoplegia n, techniques in, 439- Ophthalmoscopy, 1 63-1 64 Optical
249 440 penalization, 289, 289f Optokinetic
Muscle paretic nystagmus, 257t-258t auditory biofeedback in, 441, 442f nystagmus (OKN) testing,
Myasthenia gravis, 242-243, 242t case study of, 448-449, 449f 156-158, 158f
diagnosis of, 438 intermittent Orbit, fracture of, 247-248
photic stimulation in, Orthophoria
440-441, 440f basic, with restricted zone, 96, 96f
optical management in, 438^439, visin therapy n, 469
439f
Index 603
Orthopic fusin, 389-390, 389f, 390f, efficacy of, 307-308 Psychogenic amblyopia, 144
494_496, 495f Orthoptics, Vodnoy afterimage method of, 308, Psychogenic strabismus, 103
263. 5ee a/so Binocular 308f Psychometric chart testing, 151-153,
visin therapy Pleoptophor, 306 151f, 152f-153f, 154f Pupil
Plus-lens defects, in amblyopia, 148 Pursuit eye
in esotropa, 369 movements, 8, 9f, 35-38,
Palsy, 238 in exotropia, 402-403 36f, 36t
myogenic, 242-245, 242t, 244t for visual skills efficiency, 464-465 afterimages and, 37 in amblyopia,
neurogenic, 238-242, 238t, 240f, Point zero, 137 Pola-Mirror 147-148 characteristics of, 35-36
240t, 447-448 Panum's n antisuppression therapy, 362, 363f defects in, 35-36, 37-39 direct
fusin reas, 11 Paradoxical in exotropia, 418 Pola-Mirror test, observation of, 36, 36f Heinsen-
anomalous retinal corre- 139-140 Position maintenance. 5ee Schrock scale for, 36-37,
spondence, 169, 170f, 171f Fixation Practice management, 543- 36t
Paralysis, terminolgica! use of, 111 546 Southern California College of
Paresis, 238. See a/so Strabismus clinic, 545 Optometry 4+ test for, 36,
terminological use of, 111 Paretic group, 545 36f, 38
strabismus. See Neurogenic palsy in ophthalmologic office, 545-546 testing of, 36-37, 36f, 36t, 38
Parietal lobe, lesions of, 250 Parinaud prvate, 544 Preferential looking tests, training of, 304, 305f, 460-462, 460t
syndrome, 250-251, 251t Parkinson's for visual acu- flashlight chase in, 532-533
disease, 251-252, 251t Past pointing, ity testing, 156, 157f Presbyopic Marsdenball in, 531-532 sequence
121 exophoria, 93 Primary microtropia, 230 of, 543 standing rotator n, 531, 532f
Patching. SeeOccIuders; Occlusion Prism(s), 200, 200f. 5ee a/so Prism pre-
Penalization, 287-291 scription R
efficacy of, 290-291 n amblyopia therapy, 291-292, 292f Random dot E stereopsis test, 60f
farpoint, 288-289, 288f diopter-degree conversin for, 557 Randot stereopsis test, 60f, 61 f, 65
near, 288, 288f in esotropa, 369 Rapport, n binocular visin therapy,
optical, 289, 289f flipper, 384, 384f, 386 273-275, 274t
total, 288, 288f in occlusion therapy, 291-292, 292f Reading, 473-474
without spectacles, 287 Risley, 53 Prism compensation, dysfunction of, 21-22
Pencil push-aways 402-403, 432- in monocular fixation training, 299
in esotropa, 497-498, 497f 433, 432f, 433f Prism policy statement on, 549-550
in exotropia, 412-414, 507-509 displacement, 437 Prism pursuit eye movements and, 37
Pencil push-ups, in exotropia, 412- overcorrection, 327-328, 327f, Visagraph testing in, 474^76, 475f
414 ; 507-509, 508f Penlight 343-344 interpretation of, 476-479
and filters, 356-357, 356t Perception, Prism prescription Rectus muscles, 5-6, 6f, 7f Red
simultaneous, 58 Percival's criterion, adaptation test for, 92 filter
78, 90t, 91 Periodic alternating associated phoria criterion for, 85, in amblyopia, 291
nystagmus, 257t- 87, 91 in antisuppression therapy, 310-311
258t Periphral clinical wisdom criterion for, 77, 90- in occlusion therapy, 291 Red lens
fusin rings 91,90t test, 140 Red print, n antisuppression
in esotropa, 380-381, 381 f, 500- confirmation procedure for, 91-92 therapy,
502, 501 f criteria for, 76-78 validity 310-311
in exotropia, 408 of, 87-90, 89t Reflex fusin test, 54-57, 56t, 57t
Philosophy of binocular visin therapy, Morgan's expected criterion for, 77 Refraction
263-268 Percival's criterion for, 78, 90t, 91 n amblyopia, 163, 280-281
of Javal and French school, 263-265, Sheard's criterion for, 77-78, 90t, 91 in esotropa, 368, 369
264f, 265t Sheedy's criterion for, 85, 87, 90t, 91 in exotropia, 401
optometric, 265f, 265t, 267-268 Prism-rack afterimage technique, 338 visual skills efficiency and, 20
of Worth and English school, 265f, Prognosis, n strabismus, 190-199, 190t. Reindeer stereopsis test, 60f Relative
2645t, 2765-267 Phoria line, 5ee a/so Strabismus, prognosis for accommodation, 42-43, 42t,
72, 73f Photic stimulation, 440-441, Progressive supranuclear palsy, 251 49
440f Photophobia, 226 Projected base-in sudes, 382f, 385-386 Relative convergence, 52-54, 53t, 54t,
Photorefraction, 165-166, 1 66f Picture Projected base-out slides, 411-412, 55t
card testing, 153-154, 156f, 157f Pierce 518-519 at far (negative), 52-53, 53t, 54t
saccade test, 28-30, 30t, 34t Proptosis, 243 at near (positive), 53-54, 55t Relative
Pilocarpine, for penalizaron, 287 Pseudo-Argyll Robertson pupil, 240 scotoma, 137 Relative vergence, 52-
Pleoptics, 305-309 Pseudo-Graefe's sign, 240 54, 53t, 54t, 55t Remy Separator, 359,
Bangerter's method of, 306 Pseudomyopia, 44-45, 45t 388-389, 388f, 389f, 496-497
Cppers' method of, 306-307, 307f,
308-309, 309f
604 Index
Resolution techniques, in monocular fix- electronic fixation instruments for, Skeffington, A. M., 267 Sliding
ation training, 297-300, 299f, 527-528 sequence of, 543 vergence training,, 270t, 271 Small
305 Restricted zone, basic sequential fixator in, 529-530 object counting, 299 Snellen chart
orthophoria with, voluntary, 24 testing, 149-151, 150f Southern
96, 96f Retinal Saccadic velocities test, 114 Saladin California College of Optometry 4+ test
correspondence, 11-12, 166- Near Point Balance Card, 79, of fixation, 38-39, 40t of pursuit
185. See a/soAnomalous reti- 80f, 81,84, 90 SCCO 4+ test of eye movements, 36, 36f,
nal correspondence fixation, 38-39, 40t of pursuit eye 38 for saccadic eye
postoperative, 341-342 Retinal movements, 36, 36f, movement testing,
function testing, 165 Retinal image 38 SCCO system, for 24, 25f
disparity, 15-16 Retinal rivalry, 16, 16f saccadic eye move- Spasm of accommodation, 44^5, 45t
Retinoscopy in accommodation testing, ment testing, 24, 25f S-chart Spasmus nutans, 255, 255t Spatial
43^4, 43f, testing, 151-153, 151f, 152f- localizaron testing, 121 Spiral of
44f, 441, 45, 45t in amblyopia, 153f, 154f Tillaux, 5, 6f Sports visin, 481
163 Retraction syndrome (Duane), 245- Scotoma Spriangle Vectogram, 47 Squint mask,
246, n amblyopia, 164 263, 264f Standing rotator, n pursuit
246f, 444-446, 445f Revell, relative, 137 eye movements, 531, 532f
graded occlusion method of, Seesaw nystagmus, 257t-258t Self- Steadiness of fixation training, 302-303
326 Rewards, in binocular assessment test, 567-588 Sensory and Step vergence training, 270t, 271, 410
visin therapy, motor fusin training in acquired Stereoacuity. See a/so Stereopsis
273-275, 275t noncomitant deviation, calculations for, 556 Stereopsis, 3-3,
Rising eye sign, 241 Risley 433-434 14-15, 15f, 59-65 in binocular visin
prisms, 53 in exotropia, 403-404 Sensory fusin, screening, 63-64,
13, 57-65 alternation theory of, 16, 16f 64f
color, 13, 50 in esotropa, 370-371 first central, 14, 15f
Saccadic eye movements, 7, 8f, 9f, 22- degree (superimposition), 14 fat fusin enhancement of, 469-470, 543
35 in, 58-59 form, 13 global, 64 linear displacement method
in amblyopia, 147-148 automated, neural summation and, 16 retinal testing of,
25 dysfunction of, 21, 23 foveal tag correspondence and, 15 retinal 59-60, 62-63, 62t, 63t
with, 303 functional problems with, image disparity and, 15-16 retinal local, 63-64 norms for, 64-65,
23 gross, 23-24, 28-30, 30t, 33-34 rivalry and, 16, 16f second degree 65t percentage of, 63 peripheral,
objective testing of, 23-27, 35 (fat), 14 simultaneous perception in, 14, 15f vectographic testing of,
Heinsen-Schrock system for, 24- 58 stereopsis in, 59-65. See a/so 59, 60f,
25, 25t Stere- 61f
sequential fixation tests for, 27, 29f opsis Strabismus, 5, 101-133 abnormal head
Southern California College of superimposition in, 58 theories of, 15- posture in, 121-122,
Optometry method for, 24, 16 third degree (stereopsis), 14-15, 15f 229
25f Sensory fusin disruption syndrome, accommodative, 192, 192t
Visagraph for, 25-27, 26f, 27f, 28f, 436 accommodative-convergence/
29f Sensory strabismus, 233-234 accommodation ratio in, 132
perceptual inhibition with, 23 Sequential fixation tests, 27, 29f acquired, 102, 191-192, 192t
sequential, 26-27, 27f, 28f standard Sequential fixator, in saccadic eye alternating, 103, 132, 132t
scoring system for, 34-35, movements, 529-531 amblyopia and, 144, 318-320. See
34t Sheard, C, 267 a/so Amblyopia
subjective testing of, 27-34, 35 Sheard's criterion, 77-78, 90t, 91 anomalous retinal correspondence
Developmental Eye Movement Test Sheedy Disparometer, 84, 90 Sheedy's n, 166-185. See a/so Anomalous
for, 31-33, 32f,33f King- criterion, 85, 87, 90t, 91 Sherrington's retinal correspondence comitancy
Devick test for, 30-31, 31f, law, 7, 9f Simulated (pseudo) of, 110-126. See a/so
31t divergence excess, Comitancy
Maples oculomotor test for, 33-34 94 n congenital nystagmus, 255
Pierce test for, 28-30, 30t visin Simultaneous perception, 58 consecutive, 234 constant, 102-103,
training for, 455^59, 456t, Single-object method 126, 127t cosmesis in, 133-134,
457t, 458f, 459f Ann Arbor in comitancy testing, 122-123 in 134t, 197-
(Michigan) Tracking in, diplopia testing, 122-123 Sixth 198, 198f
529, 530f cranial nerve palsy, 239 cross-fixation pattern in, 132-133
case study of, 470-472, 471 f, 472f developmental history n, 104-105
continuous motion n, 528-529,
528f, 529f
Index 605
deviations of. See a/so Esotropa; periodic, 126, 127t Suppression, 135-143 amblyoscope
Exotropia pharmacologic treatment in, workup for, 141-143,
direction of, 128-130, 128t, 130f 204-205 142f, 143f
frequencyof, 126-128, 127t previous treatment for, 1 04, 1 04t Bernell's three-figure test for, 141
magnitudeof, 130-132, 131t, 133 primary deviation in, 112-113, 114d central, 137-138, 139t
measurement of, 105-110, 105t, 106f, prognosis for, 1 90-1 99, 1 90t AC/A characteristics of, 136-139, 138f,
107f, 108f, 109f, 109t, 110f ratio and, 1 94 accommodative 139t
primary, 112-113, 11 4f infacility and, deep, 138-139, 139t foveal, 137,
recording protocol for, 118-121, 120f 196 139t intensityof, 138-139, 139t
secondary, 112-113, 11 4f age and, 1 96-1 97 amblyopia and, pathologic, 136 peripheral, 137-138,
variability of, 133 diplopia with, 13, 121 195 anomalous retinal 13 9t physiologic, 23, 136 Poa-
direct, 127 direction of, 128-130, 128t correspondence Mirror test for, 139-140 red lens test
classification of, 128, 128t and, 195-196 centration- for, 140 shallow, 138-139, 13 9t
testingfor, 128-130, 130f duration of, 1 point testing and, 196, testingfor, 139-143, 140f, 142f, 143f
03-1 04 examination record for, 554-555 197f treatment of, 310-312, 311f, 347-
eye dominancy in, 133 eye laterality in, comitancy and, 194 cosmetic 365. See a/so Antisuppres-sion
132-133, 132t frequencyof, 126-128, factors and, 197-198, therapy
127t 198f Worth dot test for, 140-141
patient history of, 127 deviation variables and, 1 94 Supranuclear horizontal gaze palsy,
testingfor, 127-128 functional cure of, dominancy and, 194 fair, 209-210 249-250 Supranuclear
190-197, 192t, 193t fairtogood, 210-211 Flom criteria vertical gaze palsy, 250-
criteria for, 1 90 and, 190 functional cure and, 1 90-1 252, 2S1t
head posture and, 121-122, 122t Hess- 97, 1 92t, Surgery
Lancaster testing in, 123-126, 193t in accommodative esotropa, 217 in
123f, 124f, 125f, 126f indirect, 127 good, 211-212 laterality and, 194 acquired noncomitant deviation,
infantile, essential, 102 intermittent, 102- poor, 206-208 poor to fair, 208- 434-435
103, 126, 127t Maddox rod test in, 129, 209 sensory fusin at centration in comitant vertical deviations, 233
130f magnitudeof, 130-132 classification point n congenital nystagmus, 441-443 in
of, 131, 131t and, 196 consecutive strabismus, 234 in
testingfor, 131-132 measurement of, 1 stereopsis level and, 190-191 esotropa, 372, 372t
05-1 1 0, 1 05t suppression and, 194 n Graves' disease, 244
altrnate cover test for, 1O8-109, psychogenic, 103 n high AC/A accommodative esotro-
1 09f, 1 09t angle kappa for, 105- ratio measurement of, 1 06-1 O7, 1O7f pa, 220
106, 106f secondary deviation n, 1 12-1 13 in infantile esotropa, 223-224, 224f
" "
sensory, 233-234 signs and in primary comtant esotropa, 224-
, , te>.J72.,
\\^QX <o^eK \i^?C \CK\ ^rt i ^^^ symptoms 372X of, 121-122, 225, 224t
our base-out pnsm tesx for, AO9- 554-555 subjective angle of n primary comitant exotropia, 227
110, 110f directionalization retinal correspondence after, 341
Hirschberg test for, 106-107, 1 07f of, 129 suppression in, 135- 342
" - ^ 2 ^ 143. See a/so
u
108f
J08t
37 77
nilat ^' oQ onA ?nnf 263- inAandVpatterns, 229
-m\m\l^^A^
1 . . t
' er
al
,
1
0
s . 4
f/
3, 132, 132t
noncomitant, TI O, m, 1T3f. 5eea/so var/ab/iy in, 133 Synoptophore, 141-143, 142f, 143f
Comitancy
von Craefe method testing in,
182-183
nonperiodic, 127, 727t 5Sr4Sjs:.oje ^~~ J ..~ ______________________________________________________________________________________________ -^ -w^
Index 607
saccadic eye movement training for, 455-459, 456t, 457t, Visuoscopy, 160-161, 161f, 162f, 231
458f, 459f Vodnoy afterimage method, 308, 308f
case study of, 470-472, 471 f, 472f Voluntary convergencetechnique, 407,
sports and, 481 506-507, 507f
stereopsis enhancement for, 469^170 von Graefe, ocular myopathy of, 244-
ergence range improvement for, 245
466-469 von Graefe method, in strabismus, 129
visual acuity and, 557 von Graefe's sign, in Graves' disease,
Visual Symptoms Survey, 561 243
Visual tracing, 296, 298f
Visual tracking, 311 W
Visually evoked potentials, 158-159, 158f, 159f Wayne Perceptuomotor Pen, 296, 297f
Wesson Fixation Disparity Card, 79, 81, 81f, 84, 90
Worth, C, 265-267, 265f
Worth dot test, 140-141, 140f
X
X pattern, 228