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Contents

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

Visual Skills Efficiency I 19


Patient History | 21
Maladaptive Behaviors | 21
Reading Dysfunction | 21
Saccadic Eye Movements | 22
Pursuit Eye Movements | 35
Fixation | 38
Accommodation | 40
Vergences | 49
Sensory Fusin | 57
Recommendations on the Basis of Test Results 65

Heterophoria Case Analysis I 69


Tonic Convergence and Accommodative-Convergence/
Accommodation Ratio | 70 Zone of Clear,
Single Binocular Vision | 72 Morgan's Normative
Analysis 76 Criteria for Lens and Prism
Prescription | 76 Fixation Disparity Analysis | 78
Validity of Diagnostic Criteria | 87
Recommendations for Prism Prescription | 90
Vergence Anomalies 92 Bioengineering Model
| 97

Strabismus Testing I 101


History | 101
Measurement of Strabismus | 105
Comitancy | 110
Frequency of the Deviation | 126
Direction of the Deviation 128
Magnitude of the Deviation | 130
Accommodative-Convergence/Accommodation Ratio |
Eye Laterality | 132 132
Eye Dominancy | 133
Variabi I ity of the Deviation | 133
Cosmesis | 133
vii
Contents

Sensory Adaptations to Strabismus 135


Suppression | 135
Amblyopia | 143
Anomalous Correspondence ) 166

Diagnosis and Prognosis I 189


Establishing a Diagnosis j 189
Prognosis | 190 Modes of Vision
Therapy | 199 Case Examples | 206

Types of Strabismus I 215


Accommodative Esotropa | 215
Infantile Esotropa | 220 Primary
Comitant Esotropa | 224 Primary
Comitant Exotropia | 225 AandV
Patterns | 227 Microtropia | 229
Cyclovertical Deviations | 232
Sensory Strabismus | 233
Consecutive Strabismus I 234

8 Other Oculomotor Disorders I 237


Neurogenic Palsies | 237
Myogenic Palsies | 242
Mechanical Restrictions of Ocular Movement | 245
Internuclear and Supranuclear Disorders | 248
Nystagmus | 252

Part TwoTreatment
9 Philosophies and Principies of Binocular Vision
Therapy I 263
Philosophies | 263
Principies | 268

10 Therapy for Amblyopia I 279


Management of Refractive Error | 280
Occlusion Procedures | 281
Monocular FixationTraining | 293
FovealTagTechniques | 300 Pleoptics
| 305
Binocular Therapy for Amblyopia | 309 Case
Examples | 313

11 Anomalous Correspondence Therapy I 323


Therapy Precautions | 323
Sensory and Motor Therapy Approaches ) 324
Occlusion Procedures | 325
Optical Therapy | 327
Major Amblyoscope | 328
Training in the Open Environment | 336
Contents ix

Exotropia and Anomalous Retinal Correspondence | 340


Surgical Results n Cases of Anomalous Retinal
Correspondence | 341
Case Management 342
Case Examples | 343

12 Antisuppression Therapy I 347


Occlusion Antisuppression Therapy | 348 General
Approach to Antisuppression Training 348 Specific
Antisuppression Techniques | 354 Management
Considerations | 363 Case Example 364

13 Vision Therapy for Eso Deviations I 367


Diagnostic Considerations | 368
Vision Therapy Sequence for Comitant Esotropa | 368
Vision Therapy Sequence for Esophoria 373
Specific Training Techniques 373
Case Management and Examples 391

14 Vision Therapy for Exo Deviations I 399


Diagnostic Considerations | 400
Vision Therapy Sequence for Comitant Exotropia | 400
Vision Therapy Sequence for Exophoria 405
Specific Training Techniques 406
Case Management and Examples | 419

15 Management of Noncomitant Deviations, Intractable


Diplopia, and Nystagmus I 429
Infantile Noncomitant Deviations | 429
Acquired Noncomitant Deviations | 430
Intractable Diplopia | 435 Congenital
Nystagmus | 438 Acquired Nystagmus
443 Case Examples | 444

16 Therapy for Vision Efficiency I 451


Visual Comfort and Performance | 452
Aniseikonia | 452
Monovision | 455
Saccadic Eye Movements 455
Pursuit Eye Movements | 460
Accommodation | 462
Vergences 466
Stereopsis | 469
Case Examples | 470
Future Directions n Binocular Vision Therapy | 473

Pa rt Th reeTec h n q u es
17 Vision Training for Eso Deviations I 489
MirrorStereoscope(T13.2,T14.4) | 490
Contents

Dual Polachrome llluminated Trainer Vectograms and Tranaglyphs


for DivergenceTraining at Near (T13.8) | 491
Aperture-RuleTrainer, Double Aperture (T13.13) \ 492
Orthopic Fusin (T13.15) \ 494
Remy Separator (T13.14) | 496
Pencil Push-Aways with Base-ln Prism (T14.13,
Pencil Push-Ups and Push-Aways) | 497
Brock String and Beads with Base-ln Prism (T13.6) | 498
BrewsterStereoscope(T13.3,T13.4) | 499
Peripheral Fusin Rings (T13.7) | 500
Televisin Trainers and Base-ln Prisms (T12.8) j 502
18 Vision Training for Exo Deviations I 505
Voluntary Convergence (T14.1) | 506
Pencil Push-Ups and Push-Aways (T14.13, T11.13, T14.1) | 507
Brock String and Beads (T14.5, T13.6) | 509
Three-DotCard(T14.6) | 511
Aperture-Rule Trainer, Single Aperture (TI 4.12) | 512
Vectograms and Tranaglyphs: ConvergenceTraining at Near
(T14.9) | 514 Vectograms and Tranaglyphs:
Convergence Walk-Aways
(T14.10) 517 Vectograms and Tranaglyphs:
Projected Base-Out Slides
(T14.11) I 518
Chiastopic FusinColored Circles (T14.14) | 519 Chiastopic
FusinEccentric Circles (T14.14) | 521 Vergence Rock
Televisin Trainer and Prisms (T14.16) | 522 Vergence RockBar
Reader and Prisms (T14.17) \ 523
Vergence RockFraming and Prisms (TI 4.18) 525
19 Vision Training for Saccades, Pursuits,
and Accommodation I 527
Electronic Fixation Instruments for Saccades (TI 6.12) | 527
Continuous Motion for Saccades (TI 6.6) | 528
Ann Arbor (Michigan) Tracking (T10.7) | 529
Sequential Fixator (T16.10) | 529
Standing Rotator for Pursuits (T16.13) | 531
Marsden Ball (T16.14) | 531
FlashlightChase(T16.17) 532
Hart Chart Near-Far Rock (T16.22) | 533
Plus-and Minus-Lens Rock (T16.23) I 537
OtherTrainingTechniques | 538
20 Sequencing of Techniques and Practice
Management I 539
Suggested Sequencing of Tra'm'mgTechniques for Amblyopia | 540
Suggested Sequencing of Training Techniques for Eso
Deviations | 540 Suggested Sequencing of
Tra'm'mgTechniques for Exo
Deviations | 541
Vision Training for Visual Skills Efficiency | 543
Practice Management in Vision Therapy | 543
Comments I 546
Contents XI

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

Self-Assessment Test | 567


Questions | 567
Answers | 579

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

Valu of Normal Binocular Vision 3 Retina! Correspondence 11


Anatomy of the Extraocular Muscles 5 Panum's Fusiona! reas 11
Neurology of Eye Movements 6 Singleness Horopter 11
Accommodation 6 Conjgate Gaze Physiologic Dipiopia 12
Movements 6 Saccades 7 Pathologic Dipiopia 13 Types
Vestbulo-Ocular Eye Movements 7 of Sensory Fusin 13
Pursuits 8 Vergences 8 Color Fusin 13
Sensory Aspeis of Binocular Vision 10 Form Fusin 13 Theories of
Monocular Considerations 11 Sensory Fusin 15 Binocularly
Driven Cells and Ocular Dominance
16

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

Monocular Temporal Crescent Monocular Temporal Crescent

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

Percentage of Impr oyerpent of


Task Scores under Binocular Conditons Stgnf eaee (Studerrt*s fr-test)

Puttng sticks in holes 30


Needle threading Card 20
fling 9
Placing pegs in grooves 4 Q.01
Reading (word decoding) 4 0.05
Letter counting on vdeo dfsplay 2 NS
terminal Beanbag tossing
-1 ' NS -
NS = not signiflcant.
Source: Adapted from } Sheedy 1L Baitey, M Muri, E Bass. Binocular vs, monocular task performance. Am } Optom Physlol Qpt.
1986;63(10):839-846.

tigators concluded that stereopsis provides a performance advantage for many different Jobs, par-ticularly
those requiring nearpoint eye-hand coordi-nation. Persons in several occupations (e.g., pilots, microsurgeons,
cartographers) are aided by stereopsis in performing their tasks safely and efficiently.
Strabismus affects only a small percentage of the population (1.3-5.4%),5 but other deficiencies of
binocular visin, such as convergence insuffi-ciency and accommodative infacility, are much more
prevalent and may result in bothersome symptoms and inefficient performance. Except for those individuis
who have acquired strabismus and experience persistent double visin, most constant strabismics report few
extraordinary visual symptoms. On the other hand, many nonstrabismics with binocular visin
dysfunctions experience a variety of anomalies that are visual in origin, such as ntermittent blur at far or
near, tired eyes after reading or viewing a computer monitor, "eye-strain" at day's end, the appearance
of jumping or moving print, vision-related headaches, reduced depth perception, and mild photophobia.
Many of these symptomatic individuis experience "binocular efficiency dysfunction" (see Chapter 2).

ANATOMY OF THE EXTRAOCULAR MUSCLES


Three pairs of extraocular muscles control the movements of each eye: a pair of horizontal rec-
tus muscles, a pair of vertical rectus muscles, and a pair of oblique muscles. The rectus muscles, the
superior oblique muscle, and the leva-tor muscle (controlling the upper eyelid) are attached to the
bones at the back of the orbit by a tendinous ring (the annulus of Zinn) that sur-rounds the optic
foramen and part of the superior orbital fissure. The four rectus muscles, optic nerve, ophthalmic
artery, cranial nerve VI, and two branches of cranial nerve III form a muscle cone (Figure 1-2). The
insertions of the rectus muscles are not equidistant from the corneal limbus but form a spiral, known
as the spiral of Tillaux, with the superior rectus inserting farthest away from the limbus (7.7 mm) and
the medial rectus inserting nearest to the limbus (5.5 mm) (Figure 1-3). The more advanced the
nsertion, the greater the mechanical advantage of the muscle (e.g., the medial rectus as
compared with the superior rectus).
As with the rectus muscles, the superior oblique muscle originates from the annulus of Zinn, but
it courses along the superior medial wall of the orbit to the trochlea, a U-shaped fibrocartilage, that
acts as a pulley. Near the trochlea, the muscle tissue becomes a tendn as it passes through the
trochlea and then reflects back normally at an angle of approximately 51 degrees to the medial wall. The
muscle then crosses the globe superiorly, passing under the superior rectus, to insert n the posterior,
superior quad-rant near the vortex veins. The trochlea, there-
Chapter1

Levator Superior SR
Palpebrae^ obligue
Superior
Rectus

A LR = :
?
Oculomotor
Foramen
Inferior
Rectus
Pulley IR
Inferior -12mm
Oblique
- 24mm

FIGURE 1 -2Lateral view of muscles of trie right eye.

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

Conjgate Gaze Movements


NEUROLOGY OF Conjgate eye movements are tndem movements
EYE of the two eyes, known as versions. These are sac-
MOVEMENTS cades, vestbulo-ocular movements, or pursuits.
The neurology of the following systems are dis- These three eye movement systems share a com-
cussed briefly: accommodation, conjgate gaze mon final pathway to the extraocular muscles, but
movements, and vergence.
Chapter1

that carry the eyes from one target to another pre-


determined target.9 The anatomy subserving vol-
51 < untary saccades has been partly established by
monkey studies and clinical observation in
humans. For example, if there s an ntention for
Medial dextroversion (eye movement to the right), stimu-
Wall lation occurs n Brodmann's rea 8 (frontal eye
field) in the frontal lobe of the left hemisphere.
Impulses then travel to the right pontine gaze cen-
ter and are forwarded to the ipsilateral nucleus of
cranial nerve VI. Subsequently, the lateral rectus
muscle of the right eye contracts. Simultaneously,
impulses travel from the ipsilateral pontine gaze
center up through the medial longitudinal fascicu-
lus that decussates to the left third nerve nucleus.
That results in contraction of the medial rectus of
the left eye (Figure 1-6). Because yoked muscles
FIGURE 1-4Relation between the superior oblique muscle and the have equal nnervation (Hering's law),10 the two
superior rectus muscle. (Note: Both the inferior and superior oblique eyes move n tndem. Versions are not restricted
muscles form a 51-degree angle with the medial wall, and both the because of the simultaneous relaxation of the
inferior and superior rectus form a 23-degree angle with the medial
wall. The action fields for clinical purposes are approximately 50 and
antagonistic yoked muscles (Sherrington's law of
25 degrees for the oblique and vertical recti, respectively.) reciproca! nnervation)10 (Figure 1-7).

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.

accommodative vergence, stimulated by blur,


and fusional vergence, stimulated by retinal
image disparity. Vergences are consciously con-
10 Chapter1

Retinas Blur Disparity

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

singleness diplopia singleness

Fixatton
Spot

FIGURE 1 -10Singleness (haplopia) horopter. Diplopia can occur for


an object that is not within the horopter.

noncorresponding points. In other words, the visual


worid outside the singleness horopter should theo-
retically appear as double when retinal stimulation
is sufficient. Fortunately, nature is grand: Physiologic
suppression usually eliminates physiologic diplopia
so that most people can go about living normal
Uves, at least visually. Similarly, nature provides sen-
sory antidiplopic mechanisms for the strabismic
individual in the forms of anomalous retinal corre-
spondence and pathologic suppression (as dis-
cussed in Chapter 5).

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

object and the patient's nose. If the patient's Fixation


Spot
attention s drawn to the nonfixated finger, then
the finger usually appears to be double, like two
ghost images. Patients who have active suppres-
sion of one eye due to a binocular visin disorder
often cannot easily see the diplopic image. Physi-
ologic diplopia is an important tool n visin
training, used to help remedate binocular visin
n both strabismic and nonstrabismic cases.

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

Fixation Whereas diplopia results from stimulation of non-


Spot corresponding retinal points, superimposition of two
-------------------- >
ocular images (e.g., a bird in a cage) requires stimula-
tion of retinal reas having common visual direc-
tions. Worth20 classified superimposition as "first
degree fusin." The importance of superimposition
testing is in measuring the subjective angle of direc-
tionalization (angle S) and also assessing the degree
of suppression, particularly in strabismic patients.
Worth20 classified fat fusin as "second-degree
fusin." This is true fusin but without stereopsis.
Fat fusin is defined as "sensory fusin in which
the resultant percept is two-dimensional, that is,
occupying a single plae, as may be induced by
viewing a stereogram in a stereoscope in which
the separation of all homologous points is identi-
cal."10 The most important reason to consider fat
fusin is for visin testing and training purposes, as
in phorometry measurements, fixation disparity
testing, and in amblyoscopic assessment and treat-
ment (i.e., major amblyoscope instrumentation).
Worth20 classified stereopsis as third-degree
fusin. Stereopsis may be defined as "binocular
visual perception of three-dimensional space based
on retinal disparity."10
Figure 1-14 illustrates central stereopsis: The
fused, small vertical une is perceived as being
closer than the star. Although there is lateral dis-
FIGURE 1-13Rathologic diplopia in an example of esotropa of the
placement of the vertical line, as seen by each eye,
right eye. The diplopia is homonymous (uncrossed). (f = fovea.)
there will be fusin of the two lines into one verti-
cal line which appears centered (but closer) with
respect to the star. Lateral displacement of such
spaceanalogous to a vein of gold in the side of a
types of stimuli to produce stereoscopic depth is a
granite mountain.
feature of many visin therapy targets, such as vec-
Form fusin is the driving forc behind good
tographs (Vectograms), anaglyphs, and stereo-
binocularity, as it is the blending of form informa-
grams (as in this example).
tion from the two eyes.
When the laterally displaced stimuli are located
Diplopia is the simultaneous perception of two
more than 5 degrees from the center of the fovea,
ocular images of a single object. This sensory phe-
peripheral stereopsis is being evaluated. In Figure
nomenon is important in clinical assessment and
1 -15, the "Y" appears to be closer to the patient and
visin therapy. As discussed previously, physiologic
the "X" farther away in relation to the star. Clinicians
diplopia testing refers to the perception of diplopic
also describe stereopsis as "gross" or "fine." Periph-
images that lie outside the singleness horopter.
eral stereopsis is necessarily classified as being
Physiologic diplopia training is frequently useful in
"gross," whereas central stereopsis is considered
visin therapy to break pathologic suppression and
"fine" if it measures 200 seconds of are or better.
to increase vergence ranges.
Stereoscopically fused images appear to be
Clinicians use many tests involving pathologic
nearer to a bifixated reference point if Panum's
diplopia, particularly as part of strabismus evalua-
reas are stimulated temporally from the center of
tions. In cases of noncomitant strabismus, for exam-
the foveas. Conversely, if Panum's reas are stimu-
ple, pathologic diplopia testing is very important in
lated nasal ly from the center of the foveas, an
determining the severity of underactions and over-
image seems farther from the bifixated reference
actions of extraocular muscles in various positions
point. If we think of the temporal retina as having
of gaze.
Chapter1 15

Une in Temporal Panum's rea Line in


Temporal
Panum's
rea FIGURE 1-16Stereopsis vales for
FIGURE 1-14Stereogram for central stereopsis induced nearer and farther perception. Plus signs indcate nearness, which is
by laterally displaced vertical Unes. The fused vertical une appears also referred to as "crossed dis-parity." Minus signs indcate far
closer than the star because the temporal (to the fovea [f]) Panum's distance, or "uncrossed disparity." The greater the temporal Panum's
rea is stimulated in each eye. rea (larger plus signs) the greater the stereopsis effect, as s true also
for the nasal Panum's rea (minus signs). (f = fovea.)

Generally speaking, the finer the degree of ste-


positive vales for nearness and of the nasal retina reoscopic discrimination, the higher the quality of
as having negative vales, we can more easily binocular visin. Conversely, suppression and
understand the concept of stereopsis related to lat- excessive fixation disparity tend to decrease stereo-
eral displacement. The greater the distance from the acuity; these anomalies often predispose a patient
center of the fovea, the greater the valueither to asthenopic symptoms and reduced visual perfor-
positive or negativefor the perception of objects mance. The main valu of stereopsis is as a clue to
appearing nearer or farther, respectively. This con- depth at cise viewing distances; its valu to the
cept is llustrated in Figure 1-16 by the increasing individual is barely significant at far distances.21 For
sizes of the plus and minus signs toward the periph- instance, a surgeon is more likely to need stereo-
ery of the retina. scopic depth perception than is an airline pilot.
Monocular clues to depth (e.g., size, linear perspec-
tive, texture gradient, and overlap) tend to predom-
nate at far distances. Nevertheless, most passenger
airlines require their pilots to have superior stereop-
Y sis, because safety and prudence demand that every
possible perceptual clue to making accurate depth
judgments be available. This stringent criterion s
probably imposed because stereopsis is the "barom-
eter of binocular visin."

Theories of Sensory Fusin


The salient features accounting for sensory fusin
are retinal correspondence, retinal image disparity
detection, and neural summation of nformation
from the two eyes. A system of correspondence
provides feedback about whether the motor align-
ment of the eyes s in registry. Retinal image dispar-
ity detection is the stimulus to the vergence system
FIGURE 1 -15Example of target for peripheral stereopsis. (f = fovea.; to make correctional vergence eye movements.
Chapter1

fication of the two ocular images did not, in fact,


take place. This theory claimed that retinal rivalry
phenomena provided evidence that the binocular
field was composed of a mosaic of monocularly
perceived patches. Henee, no true fusin occurred;
the input for one eye would inhibit the input from
the other. Retinal rivalry of dissimilar forms, a com-
mon clinical observation, is the primary evidence
supporting the alternation theory, which purports
that the mosaic pattern of the "fused" image is
ever-changing, with certain portions at times
being dominated by the left eye's responses and
at other times by the right eye's responses (Figure
1-17). This theory left unexplained many features
of binocular perception, such as contrast sensitiv-
ity enhancement. Moreover, single-cell electro-
physiologic evidence has conclusively shown this
notion of binocular visin to be essentially incor-
rect. The more modern theory of neural summa-
tion is fundamental to binocular perception.
Studies of reaction time to binocular versus monoc-
ular visin stimulation and cortical electrophysi-
ology indcate that information from both eyes is
available during binocular viewing. 26 Binocular
fusin is characterized by summation of informa-
tion from the two eyes and synchronization of
neural activity from each eye's dominance col-
umns in the striate cortex.
FIGURE 1-17Cyclopean projection showing perception of retinal
rivalry.

Binocularly Driven Cells and


Within certain limits, retinal image disparities are Ocular Dominance
also necessary for stereopsis. Research has indi- Ocular dominance is another important physiologic
cated that certain striate cells in reas V1 and V2 (in feature of binocularly driven cells. Only approxi-
occipital reas 17 and 18) are sensitiva to horizon- mately one-fourth of these cells respond equally to
tal disparity for the perception of stereopsis.22'23 input from the right and left eye; the others respond
Studies of higher mammals have shown that more vigorously to the input from either one eye or
approximately 80% of cells in the striate cortex can the other.24 Ocular dominance of binocular cortical
be binocularly stimulated.24 Neural summation of cells is particularly sensitive to the amount of binocu-
these binocular cells has been demonstrated by sin- lar stimulation during development in infancy. Even
gle-cell neurophysiologic investigations.22 The cor- minor obstacles to sensory fusin can have long-term
responding reas, however, ,must be in proper consequences. Obstacles to sensory fusin, such as
registry for mximum responsiveness. When these anisometropia, aniseikonia, strabismus, and form
fields are out of alignment, they mutually inhibit deprivation (e.g., cataract), can result in a rapid shift
one another.25 These physiologic features are the in striate cell ocular dominance. When most cortical
basis for the perceptual unification of the two ocu- cells are controlled exclusively by one eye during the
lar images and represent some of the advantages of sensitive period, the natural consequences are binoc-
normal binocular visin. As discussed previously, ular anomalies.27 These include suppression, ambly-
contrast sensitivity and visual acuity are enhanced opia, anomalous retinal correspondence, loss of
by binocular neural summation. stereopsis, and deficient fusional vergences. Such
One of the more popular, older theories of bin- binocular anomalies may become permanent unless
ocular visin, the alternation theory, held that uni- timely and appropriate visin therapy takes place.
Chapter1 17

REFERENCES 14. Mukuno K. Electron microscopic studies on the human


extraocular muscles under pathologic conditions. Jpn J
1. Brny E. A theory of binocular visual acuity and an anal- Ophthalmol. 1969;13:35.
ysis of the variability of visual acuity. Acta Ophthalmol. 15. Dale RT. Fundamentis of Ocular Motility and Strabis-
1946-24:63. mus. New York: Grue & Stratton; 1982:105.
2. Horowtz MW. An analysis of the superiority of binocular 16. Enright JT. Slow-velocity asymmetrical convergence: a deci-
over monocular visual acuity. J Exp Psychol. 1949;39:581. sive failure of "Hering's law." Vision Res. 1996;36:3667-
3. Campbell FW, Creen DG. Monocular vs. binocular visual 3684.
acuity. Nature. 1965;200:191-192. 17. Tamler E, Jampolsky A. Is divergence active? An elec-
4. Sheedy JE, Bailey IL, Muri M, Bass E. Binocular vs. monoc tromyographc study. AmJ Ophthalmol. 1967;63:452.
ular task performance. Am J Optom Physiol Opt. 1986;63 18. Panum PL. Physiologische Untersuchungen ber das Sehen
(10):839-846. mitzwei Augen. Kiel: Schwerssche Buchandlung; 1858:52.
5. Michaels DD. Visual Optics and Refraction. St. Louis: 19. von Noorden GK. Binocular Vision and Ocular Motility:
Mosby; 1980:677. Theory and Management of Strabismus, 4th ed. St. Louis:
6. Derner JL, Miller JM, Poukens V, et al. Evidence for fibro- Mosby; 1990:17.
muscular pulleys of the recti extraocular muscles. Invest 20. Worth C. Squint: Its Causes, Pathology, and Treatment.
Ophthalmol Vis Sci. 1 995;36:1125-1136. Philadelphia: Blakiston's; 1921.
7. Clark RA, Miller JM, Demer JL. Location and stability of 21. Schor C, Flom MC. The relative valu of stereopsis as a
rectus muscle pulleys. Invest Ophthalmol Vis Sci. 1997; function of viewing distance. Am J Optom Physiol Opt.
38:227-240. 1969;46:805-809.
8. Clark R, Miller J, Demer J. Three-dimensional location of 22. Hubel DH, Wiesel TN. Stereoscopic visin in macaque
human rectus pulleys by path inflections in secondary monkey: cells sensitive to binocular depth in rea 18 of
gaze positions. Invest Ophthalmol Vis Sci. 2000;41:3787- the macaque monkey cortex. Nature. 1970;225:41.
3797. 23. Poggio GF, Poggio T. The analysis of stereopsis. Annu Rev
9. Glaser JS. Neuro-ophthalmology. Philadelphia: Lippin- Neuroso. 1984;7:379.
cott; 1990:300.
24. Hubel DH, Wiesel TN. Receptive fields, binocular inter-
10. Hofstetter H, Griffin J, Berman M, Everson R. Dictionary action and functional architecture in the cat's visual cor
of Visual Science and Related Clinical Terms, 5th ed. Bos tex. J Physiol (Lond). 1962; 160:106.
ton: Butterworth-Heinemann; 2000:284. 25. Nikara T, Bishop PO, Pettigrew JD. Analysis of retinal cor-
11. Maas EF, HuebnerWP, Seidman SH, Leigh RJ. Behavior of respondence by studying receptive fields of binocular sin
human horizontal vestbulo-ocular reflex in response to gle units in cat striate cortex. Exp Brain Res. 1968;6:353.
high-acceleration stimuli. Brain Res. 1989;499:153-156. 26. O'Shea RP. Chronometric analysis supports fusin rather
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Manual, 2nd ed. Thorofare, N.J.: Slack Inc.; 1987:51-54. 1987;27:781-791.
13. Hoffman FB, Bielshowsky A. ber die der Wilkur entzo- 27. Weakly DR Jr. The association between nonstrabismic
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chapter2 / Visual Skills Efficiency

Patient History 21 Maladaptive Behaviors Nott Method 43 Monocular


21 Reading Dysfunction 21 Saccadic Eye Estmate Method Retinoscopy
Movements 22 Saccadic Suppression 23 43
Objective Testing 23 Southern California Excess of Accommodation 44
College of Optometry System 24 Heinsen- Facility of Accommodation 45
Schrock System 24 Ophthalmography Ill-Sustained Accommodation 48
(Visagraph) 25 Sequential Fixation Tests Summary of Accommodation Testing 49
27 Subjective Testing 27 P|erce Test 28 Vergences 49
King-Devick Test 30 Developmental Eye Absolute Convergence 49 Testing
Movement Test 31 Maples Oculomotor Techniques 49 Functions and
Test 33 Standard Scoring System 34 Norms for Absolute Convergence
Summary of Saccade Testing 35 Pursuit 50 Developmental Considerations
Eye Movements 35 Characteristics 35 51
Testing of Pursuit Skills 36 Direct Relative Convergence Testing and
Observation 36 Heinsen-Schrock Scale Norms 52 Fusional Vergences at
36 Afterimages 37 Signs and Symptoms Far 52 Fusional Vergences at
37 Summary and Recommended Tests 38 Near 53
Fixation 38 Southern California College Vergence Facility 54
of Optometry Reflex Fusin 54
4+ System 38 Vergence Stamina 57
Summary of Fixation Testing 39 Summary of Vergence Testing 57
Vestbulo-Ocular Reflexes 39 Sensory Fusin 57
Accommodation 40 Insufficiency of Simultaneos Perception 58
Accommodation 40 Absolute Superimposition 58
Accommodation 41 Relative Fat Fusin 58
Accommodation 42 Lag of Stereopsis 59 Vectographic
Accommodation 43 Methods 59 Linear Displacement
Methods 59 Percentage of
Stereopss 63 Screenng for
Binocular Problems with
Stereopsis 63 Norms for
Stereoacuity 64
Summary of Sensory FusionTesting 65
Recommendations on the Basis of
Test Results 65
20 Chapter 2

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

TABLE 2-1. Hensen-Schrock System for Testng and


Rating Saccadic Eye Movements

N0 head movement (3)


Head movement, but can nbibit (2)
cades are automated (that is, occurring normally
Sfight head movement persists {1)
and simultaneously with relatively simple cogni-
tive demands), 2 points if eye movements are sta-
I ' -
All accuracles (2)
ble for 20 seconds, and 1 point f there is adequate
Sligtrt inaeeuraees f 1)
stamina when the test s continued for 1 minute.
C
Ttius, 10 possible points can be accrued using this
Automated sacc&des (2)
procedure (Table 2-1).
Reduced automatlon (1)
With regard to automated saccades, the clini-
cian should ask a simple question that is appropri- D
Stable saccades for 20 secs (2)
ate to the patient's cognitive abilities under such
Stable saccades for 10 secs (1)
circumstances. For example, a 5-year-old patient
E
might be asked his or her ame as the patient looks
Adequate stamjna (1)
from one target to the other. A 7-year-old patient
could be expected to count from 1 to 10 while Source: A, Heinsen, R, Schrock, personal communication, 1981.
maintaining accurate saccades. A 9-year-old
patient should be able to count backward from 10
to 1. An 11-year-old patient should be able to
count backward from 100 on down. A 13-year-old believe is meant by automated. Unless a reader
patient can normally be expected to count back- can automatically make accurate saccades, he or
ward from 100 by ntervals of 3. This is what we she is unlikely to visualize and concntrate on the
contents of the reading material. Frequently, during
testing of patients who have saccadic eye move-
ment problems, a cognitive demand will cause
patients to look n the wrong direction of the test
target and fail to make an accurate saccade. In
other words, the cognitive demand can make the
saccadic movements poor (and poor saccades
even poorer) unless automation is achieved. It s
conversely presumed that poor saccadic eye
movements have an adverse effect on reading
(cognitive) skills.

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

FIGURE 2-3Five-dot card designed to


test fine saccades as n the act of readi'ng.

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

FIGURE 2-4Saccadic eye movements on the five-dot test. a. Good


saccades. b. Poor saccades.

Pierce Test for saccadic eye movements. It consists of three


The Pierce saccade test,12 designed sub-tests, each of which is a series of two laterally
by Dr. John R. Pierce, was the first displaced numbers.The patient is asked to hold the
of its kind to evalate a patient's demonstration card at his or her habitual reading
gross saccadic eye movements distance and to read each number aloud, from
according to age expectancies and was the first side
normed subjective test

2 1 S 4 ^
M * . . _/ * * * * ^ J

JL <J

"JL** t t

f >^>* o^ >/ %) >?

^
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

Numbers Profile Visagraph versin 4.1


Left Right 164 164 36 38

Fixations/100 numbers
Regressions/100 numbers

Av. Duration of Rxation (sec) 0.28 0.28


Rate (numbers/min) 130

Directional Attack 23% Countable unes in text 7


Rate adj. for Rereading (numbers/min) 281 Lines found
Saccades in Return Sweeps 10
Anomalies (Fix/Regr/Both) 1/1/0
Cross Correction 0.990
ame: Test Numbers Recorded: 1 1/29/99 09:39
FIGURE 2-6Example of computer- Class: Sex: M Grade: 1 Text: t-0-0.txt
izad results of the numbers test.
School: Title: Numbers
Comment:

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 2-7Sequential fixation test


using (a) clear sheet with printed symbols
or (b) an opaque card with a viewing
30 Chapter 2

FIGURE 2-8Eye-Trac recordings (a) before and (b) after visin therapy showing improved performance for reading a paragraph.

Note the approximate 3-to-1 mprovement in 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

Pierce test. A possible problem with the Pierce and


TABLE 2-3. Samples ofNorms for the King-Devick tests, however, s that some individuis
King-Devick Test are basically slow n naming digits, independent of
their saccadic skills. Besides poor saccades, perfor-
mance can also be limited by poor attention skills,
Time in Number of deficient binocular visin, and uncorrected refractive
Seconds (total Errors (total of 3 error n children 6 years of age and older.
Age (yrs) of 3 subtests) subtests)
6 119 17
Developmental Eye Movement Test
7 101 12
The Developmental Eye Movement (DEM) Test by
8 77 3
Richman and Garzia further refines the indirect
9 79 3
approach to assessment of saccadic eye move-
10 68 2
ments.15 As n the King-Devick test, the DEM test is
11 57 1
designed to evalate both accuracy and speed of
12 54 1
fine saccades, as n the act of reading. The principal
13 52 1
difference between these two tests is that a subtest
14 50 0
of number naming in a vertical array s ncluded n
Source: A Cohn, S Lieberman. Report, In Manual of the the DEM test, presumably to determine a patient's
NYSOA-KD Saccade Test. Mishawka, Ind.: Bernell Corp.; 1993.
rapid automatized naming (RAN) ability (Figure 2-
10). As to the vertical columns, the DEM test
manual states: "This becomes a test more heavily
Devick test includes a demonstration card (Figure dominated by the individuaos visual-verbal auto-
2-9a) and three test cards (see Figure 2-9b through 2- matic calling skills (automaticity)" (see Appendix J
9d). Each test card displays eight rows of five num- for DEM source information). As in the King-Devick
bers, for a total of 40 numbers per card. The numbers test, a horizontal array of numbers s provided,
are sized to approximate 20/100 (6/30) reduced exceptthe horizontal dimensin is slightly reduced
Snellen acuity at a viewing distance of 40 cm. Testing (to simlate usual reading demands) and the quan-
is performed n a manner similar to that used for the tity of numbers s increased to 80 digits in the DEM

FIGURE 2-9King-Devick test show-


ing demonstration card and the three
subtests. a. Demonstration card. b.
Subtest with lines. c. Subtest without
lines. d. Stimuli more crowded.
32 Chapter 2

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

5432 Very strong (much above average)


1 Strong (above average) No head movement (1.5) Head
Note: A ranking of Adequate (average) movement, but can inhibit (1.0) Slight
toss than 3 s Weak (below average) head movement persists (0,5) Obvious
considered faiture as persistent head movement (0.0)
referral cri-terton for Very weak (much below average)
visin therapy. I
AII saccades accurate (1.0)
Some slight naccuracies (0.5)
Several gross naccuracies (0.0)
dation. Maples' system comes with an nstructional C
videotape that contains many fine examples of Automated saccades (1.0)
children displaying dysfunctional, but not patho- Reduced automation (0.5)
logic, oculomotor behavior. The saccadic test No automation (0.0)
involves rating of gross reflex saccades across trie D
midline n response to the tester's commands. Stable saccades for 20 secs or more (1.0)
Observations are made of basic ability to perform Stable saccades for 10 secs (0.5)
the test, accuracy of saccades, and rating of collat- Stable for lessthan 10 secs (0.0)
eral head and body movements. The same is done i
for pursuit rotations. The patient's eight scores are Stamina for 1 min (0.5)
compared with normative data for boys and girls Stamina for less than 1 min (0.0)
between the ages of 5 and 14+ years; the norms
indcate that girls mature faster than boys in these
visual skills. According to Dr. Maples, the oculo-
Standard Scoring System
motor norms for 14-year-olds are adultlike. Inter-
The aforementioned tests vary in ther scoring of
rater and test-retest reliability seem acceptable.
saccadic efficency, but a standard scoring system
Interestingly, oculomotor behavior on this test, par-
is desirable. Crffin20 reported a system for sac-
ticularly head and body movement, was found to
cades based on a 5-point scale, in common with
discrimnate between good and poor readers.
a 5-point scale for several other visual skills. In
such a scheme, each visual skill function can be
TABLE 2-5. Ranking of Saccadic Performance on
ordinally ranked from 5 (best) to 1 (worst), with
the Pierce, King-Devick, and Developmental Eye semantic differential descriptions (Table 2-4). An
adaptaton of the Pierce, King-Devick, and DEM
Movement Tests tests is shown n Table 2-5. Such a ranking system
is convenent when comparing strengths and
Rank Description Results weaknesses among various visual skills. It allows
for better understanding and commnication to
5 Very strong Two or more years above patients and interested third parties (e.g., the
patient's health nsurance company). A 5-point
average
4
mximum ranking system, which is a modifica-
Strong One year above average
3 Adequate Average performance for
tion of the Heinsen-Schrock scale, s shown n
Table 2-6. This is but one of many possible ways
age
2 Weak One year below average that a practitioner can convert other scoring sys-
1 Very weak Two or more years below tems for saccades into a 5-point scale for ordinal
average ranking.
A simplified and quick sequence of saccade
tests for the primary eye care practitioner is as fol-
Chapter 2 35

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

categories for pursuit skills with rankings of func-


tions for other visual skills, as discussed previously
for saccades. The advantage of the Heinsen-
Schrock system over the SCCO 4+ system is that
automation and stamina are taken into account
along with head movements, smoothness, and
accuracy. Either a Marsden bal I or a motorized
instrument such as the Bernell RotatorTrainer (Ber-
nell Corporation; see Appendix J) (Figure 2-13) is
ideal for this type of testing, although a hand-
held penlight that is moved smoothly and evenly
will suffice. Whatever target s used, smoothness,
accuracy, head movement, automation, and stam-
ina are to be evaluated. Using the same cognitive
demands as in saccadic testing (discussed previ-
ously) and continuing the pursuits for 1 minute will
allow for judgment of automation and stamina,
respectively.

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).

approaching ball. Therefore, statements relating to


Signs and Symptoms pursuit skills and athletic skills should be made
Patients who have poor ocular pursuit skills may with caution and with other factors (e.g., athletic
also have histories of various nefficiencies. Poor prowess) kept n rnind.
readers may have poor pursuits, although the Supranuclear lesions restrict pursuit excursions,
cause-and-effect relationship s not as great as with but nuclear or infranuclear lesions affecting the
saccadic dysfunction and poor reading. Reading extraocular muscles also can be expected to pro-
road signs from a moving vehicle would present duce many signs and symptoms. Pursuits would
problems in a case of poor pursuit skills. Patieptsr" likely be inaccurate and jerky in the diagnostic
with poor pursuit eye movements also tend to have action field of the affected muscle (see Chapter 4
significant problems participating n sports. It s regarding noncomitancy). However, these "hard"
conceivable, for example, that tracking a tennis signs of neurologic impairment are relatively easy
ball accurately would be much more difficult f to detect, explain, and understand, in contrast to
head movements were necessary, because the "soft" signs that might be supranuclear. In either
gross neck muscles are not as efficient as the case, the patient with pursuit problems due to neu-
finely tuned extraocular muscles. However, we rologic disease may have symptoms of vrtigo,
saw a patient who had Duane retraction syndrome nausea, asthenopia, or inefficient visin for mov-
involving both eyes, which severely restricted ocu- ing objects, among other difficulties.
lar activity. This patient reported being able to play Because pursuits are mainly involuntary and
tennis "fairly well," despite the fact that head turn- many of the neurologic soft signs are likely incur-
ing was necessary for the patient to see the able, one must ask how functional training tech-
38 Chapter 2

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

FIGURE 2-14Fixation testing results


from Eye-Trac recordings. a. Good,
steady position maintenance. b. Fair
position maintenance. c. Poor position
maintenance.

system allows for a 5-pont ordinal ranking system Vestbulo-Ocular Reflexes


which is compatible with our recommended scale The eyes maintain gaze on a target with rotation of
used in common for other visual ski lis (Table 2-8). the head through the neurologic control of VOR.
Head position and acceleration are sensed by the
Summary of Fixation Testing semicircular cais and otolith apparatus and are
An ophthalmographic instrument such as the Visa- communicated to the oculomotor centers n the
graph is desirable for assessment of position main- midbrain. The effect of this process s that a head
tenance. When this s not practical, as n very movement in any direction s accompanied by an
young children, a quick objective test, such as the equal and opposite eye movement, thus stabilizing
5-point system for direct observation, s recom- the eyes relative to a target. Vestbulo-ocular, neck,
mended. Therapy to improve position maintenance and body reflexes combine with optokinetic
is discussed n Chapter 16. reflexes to stabilize the retinal image as an individ-
Chapter 2

TABLE 2-8. System for Ranking Position Maintenance ACCOMMODATION


Functional disorders of accommodation can be sep-
arated into four types of problems: (1) insufficiency,
, Rank Description Results (2) excess, (3) infacility, and (4) ill-sustained accom-
modation (poor stamina). Patients can present with
5 Very strong Steady fixation for more
an accommodative dysfunction thatfalls into any one
than 10 secs or all of these categories, as the categories are not
4 Strong Steady fixation for at least mutually exclusive. In fact, many patients who can
10 secs be described as having an accommodative insuffi-
3 Adequate Steady fixation for at least ciency also show signs of infacility and poor stamina.
5 secs Two additional categories of accommodative dys-
2 Weak Steady fixation for less function are (5) unequal accommodation and (6)
than 5 secs or hand sup- paresis or paralysis of accommodation. The etiology
port needed of these last two disorders is not functional. In cases
1 Very weak Unsteady fixation almost of accommodative insufficiency stemming from neu-
continuously
rologic disease or trauma, patients are best served by
a prescription for reading glasses rather than visin
27
training. The first four categories do not imply an
ual moves through the environment. Developmen- organic etiology, as they often arise from functional
tal disorders of VOR tracking are relatively rare; causes (e.g., deficient physiology, overwork, or inat-
most deficiencies are acquired by trauma or neuro- tention). Besides describing the characteristics of an
logic disease. accommodative dysfunction, the clinician must
A complete assessment of VSE should include a determine, insofar as possible, the specific etiology
screening of VOR tracking. The patient is directed and must seriously consider the many nonfunctional
to hold gaze on a discreet fixation target at far or factors (Table 2-9) before the condition is assumed to
near, while either he or she moves or the clinician be functional in origin. A review of accommodative
gently moves the patient's head up and down for conditions and appropriate testing follows.
several cycles at the rate of 1 cycle per second.
This procedure then is repeated moving the
Insufficiency of Accommodation
patient's head from side to sidethe so-called
"doll's-head" maneuver. Smooth tracking is the Insuffidency of accommodaton is defined as "insuf-
rule. The presence of either saccadic intrusions ficient amplitude of accommodation to afford clear
("catch-up" saccades) or nystagmus indicates a imagery of a stimulus object at a specified dis -
failure in VOR tracking and should be further tance, usually the normal or desired reading dis -
21
assessed. In children, intervening saccades may tance." This-, is sometimes a problem in
indcate simply lapses of attention to the task, prepresbyopic patients and very often is problematic
which should be taken into consideration. in presbyopic patients but is not too frequent in
Further assessment can include challenging younger patients. However, pathologic conditions
VOR t rac k ing t hroug h head s h ak ing t hat is affecting the third cranial nerve, the ciliary muscle, or
greater than 1 cycle per second. Immediately the crystalline lens itself can result in paresis or paral-
after 10 to 15 seconds of head shaking by the ysis of accommodation for all age groups. The use of
patient in the vertical or horizontal pla e, the sympathomimetic (adrenergic) or parasympatholytic
practitioner should look for nystagmus using a (anticholinergic) drugs also result in symptom -
magnifier or ophthalmoscope. Another technique producing lowered amplitudes of accommodation.
is to measure binocular visual acuity before and Although isolated accommodative insufficiency in
during head shaking, both horizontal and verti - young patients is relatively rare, we saw three young
cal. Snellen visual acuity should not decrease men with isolated accommodative insufficiency
more than one line (e.g., 20/20 to 20/25) during within a 1-month period. All had a history of tropical
head shaking if there is good VOR tracking. illnesses of some kind. All had to wear bifocals to
Patients having signs or symptoms of a VOR dis- read clearly, and we happened to see them after they
order should be referred for further neurologic had been to other practitioners who insisted they did
testing. not need to wear bifocals because of their youth. The
Chapter 2 41

TABLE2-9. Possible Causes ofa Reduction of Accommodation

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

TABLE2-10. Donders'Table ofAmplitude of


TABLE 2-12. Ranking of Relative Accommodation
Accommodation (in which Dioptrc Powers Represent the First
Sustained Blur)

Age (yrs) Amplitude (D)


Rank Description PRA (-} anel NRA (+}
10 14.0

20 10.0 5 Very strong >2.5GD*


30 7.0 Strong 2.25 D
40 4.5 4 Adequate 1.7S-2.00D
50 2.5 Weak Very 1.50D
3 weak <1.50D
NRA2= negative relative accommodaton; PRA positive rela-tive
farpoint visual acuity lenses with most plus power accommodation.
The clfnician shouid beskeptical of an NRA finding exceeding +2.50
(also called CAMP lenses [corrected ametropia D at1a 40-cm testing dlstance. K NRA exceeds +250 O, ttie testing
most plus]) should be worn for testing. If the patient procetlure s wrong. Either the patlent is over-nsnused or there s
does not give reliable responses, the clinician latent hyperopia (Le., corrected ametropia most plus [CAMP1 tenses
not being wom). Theoretfcally, 40 cm s the faipoint (ptica! bflnty)
should move the target from near to far by starting wSth +2.50-D tenses. The pattenfs vbfon showld be blurred when
at the spectacle plae and pushing it away until the +2.5-D power s exeeeded, CAMP tenses, ttierefore, are absolutely
designated line of print is read aloud correctly. necessary for reliable baseline clinical data.
Then testing reverts to the push-up method until
first blur is reported. This technique is the method-
of-adjustment (method-of-limits) research tech- very young children because their clinically mea-
nique, referred to as bracketing'm clinical parlance. sured amplitudes are often lower than would be pre-
Table 2-10 is an abridged table of the amplitude of dicted theoretically. Practitioners should consider
accommodation according to age. 31A formula to this when testing children younger than 6 years.
calclate the minimum expected amplitude of Semantic confusin often arises over the term
accommodation was introduced by Hofstetter. 31 accommodative insufficiency. Some sources (inap-
The minimum amplitude is calculated as propriately, in our opinin) refer to "accommoda-
A = 15 - 0.25(x) tive deficiency" or "insufficiency" when talking
about accommodative nfaciUty. (Accommodative
where x is the patient's age in years. For example, if a infacility is discussed later in this chapter.)
patient is 10 years od, the expected amplitude is 15
- 0.25(10), or 12.5 D. An amplitude of only 8.5 D in Relative Accommodation
the right eye would be very weak, as this is 4 D
Another form of accommodative insufficiency s that
below average. Table 2-11 gives accommodative
of poor positive relative accommodation (PRA) and
ranking. The Hofstetter formula may not hold true for
poor negative relative accommodation (NRA). PRA is
tested with minus-power lenses to first sustained blur
TABLE 2-11. Ranking of Accommodative Amplitude under binocular viewing conditions. NRA is tested
similarly but with plus-power lenses. These functions
are traditionally tested at 40 cm, with the patient
Rank Description Amplitude looking through CAMP lenses for baseline reference.
The patient is instructed to maintain clearness and
5 Very strong 1 .00 D or more above singleness while looking at a designated line of letters
4 Strong 3 average 0,50 D above (20/20 [6/6] equivalent or smaller if visible) as the
Adequate 2 average Average for plus or minus lens stimulus is increased (Table 2-12).
Weak 1 Very age 2.00 D below The rate of stimulus increase s approximately every 3
weak average 4.00 D or more seconds in 0.25-D steps. A momentary blur is
below average allowed. Approximately 5 seconds should be
allowed to determine whether the blur is sustained.
The PRA and NRA are record i ngs representing the
Chapter 2 43

FIGURE 2-15Nott method of dynamic


retinoscopy to measure lag of accom-
modation.

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

FIGURE 2-16Monocular estmate


method retinoscopy (dynamic) to
assess accommodative accuracy (i.e.,
lag or lead of accommodation).

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

an anomaly. Latent hyperopia s another variation of


accommodative spasm (.e., accommodation fails to TABLE 2- 14. Ranking of Accommodative
relax using noncycloplegic ["dry"] refractive tech- Excess Using the Monocular Estmate Method
niques); cycloplegic ("wet") refraction may be indi- of Retinoscopy
cated. Causes of spasm may be overstimulation of the
accommodative system as a result of prolonged near
work, emotional problems, focal infections, or other
unknown etiologies. Numerous symptoms may be Lerts Power
associated with accommodative excess, such as Indicating Lead of
Rank Description Accommodation
asthenopia, blurring of distant visin, headaches, 5 Very strong +0.25 D
diplopia (if excessive accommodative convergence is 4 NA NA
brought into play), and inefficient performance at
nearpoint (e.g., a person may hold reading material Adequate
3 (borderline) 0.00 D -
at an exceptionally cise range).
Maintaining or sustaining accommodation n the Weak
2
1 Very weak -0.50 0.25
D or D
greater
absence of a dioptric stimulus s another form of
accommodative excess. This form is physiologic n NA = not applicable.
that it is not abnormal for accommodation of approx-
imately 1.00 D to be n play n a formless field, as in
"night myopia." There s no specific training tech- plished with the binocular crossed-cylinder test at
nique for night myopia; rather, the affected individual near. However, we do not believe this subjective
must become familiar with the set of circumstances method is as reliable as objective testing with either
in which the anomaly occurs and must make appro- the Nott or MEM method.
priate adjustments to it (e.g., temporarily wearing
minus overcorrective lenses, if necessary, for night-
time driving). Facility of Accommodation
Retinoscopy is necessary for reliable diagnosis of Another aspect of accommodation s facility. An
accommodative excess. Static retinoscopy with the infacility of accommodation, also known as inertia
aid of cycloplegia can determine ametropia (.e., far- of accommodaton, is the inability to change focus
point). At nearpoint, however, dynamic retinoscopy s rapidly. Accommodative infacility can cause dis-
important; cycloplegia must not be used n nearpoint comfort and reduced visin efficiency. For example,
testing. Either Nott or MEM dynamic retinoscopy can such patients typically report slow clearing of
be used to determine whether there is a /ag(i.e., insuf- visin, most often noting blurring when looking
ficiency), but MEM s applicable for lead(\.e., excess) from the "book to the board." The standard testing
of accommodation. If accommodative response leads procedure s to use 2.00-D lenses. The recom-
the accommodative stimulus by 0.25 D or more, we mended optotype s the equivalent of a 20/30 (6/9)
believe accommodative excess exists at that moment Une of Snellen letters at 40 cm while the lens power
of testing. This observation should be verified on is changed from plus to minus, and so on, for 1
repeated testing. lf-0.25 D is consistently required for minute. Lenses may be mounted in devices (Figure
neutralization, the patient is considered to have 2-17) that are similar to a Comparator (Bausch
accommodative excess (Table 2-14). &Lomb, Rochester, NY). Testing is done
Accommodative excess can also occur when monocularly (oculus dexter and oculus sinister) and
excessive accommodative convergence s required then binocu-larly. Suppression can be monitored
to maintain fusin, as in patients with exophoria in with vecto-graphic targets (Figure 2-18). Although
whom positive fusional convergence is insufficient. clinicians may ask the patient to say "clear" with
Such a patient may overaccommodate n order to each stimulus change, a better technique s to
have sufficient accommodative convergence to nstruct the patient to read each letter aloud as
maintain single (but blurred) visin. quickly as possi-ble with the introduction of each
Although objective means for determining accom- lens flip. This allows monitoring of correct or
modative accuracy (with Nott or MEM methods) are ncorrect responses. The number of accurate calis
reliable, especially for young patients, subjective test- is recorded and converted into cycles per minute
ing may also be performed. This can be accom- by dividing that number by 2. For example, f the
number of correct calis for an eye is 8, there are 4
cycles per minute.
46 Chapter 2

FIGURE 2-17Bernell flipper devices for accommodative facility test-


ing. (Courtesy of Bernell Corp.)

The standard flipper lens test is contaminated by a


number of factors of which the clinician must be
aware. Because a patient verbally reports when a tar-
get appears to be olear, the measurement depends to
some unknown extent on the speed or automaticity
of verbal expression. The plus and mi us lenses
noticeably magnify and minify the optotype stimulus,
possibly confounding the perception of blur. Further-
more, time and manual dexterity are involved in
mechanically changingthe lenses. Until better instru-
mentation is developed, the clinician should attempt
to mitgate these factors when possible. For example,
a patient can be instructed to ignore the apparent
change in image size and to respond only when the
optotype is perfectly clear regardless of size. The cli-
nician should handle the lenses and flip the lenses in
a consistent manner for each patient. Currently, nor-
mative data are available for most patients using the
traditional lens flipper testing modality; the variance
in norms from one study to another may be due in
part to some of the factors just cited.
A summary of norms of facility by several investi- FIGURE 2-18Accommodative facility testing: Trial lenses can be
31 mounted n an attachment for the Correct-Eye Scope. a. Monocular
gators is included in Table 2-15. Borish stated that testing; left eye is being tested n this figure, b. Binocular testing. c.
monocular accommodative facility, when tested at View of crossed-polarizing filters worn by the patient. d. Vectographic
the patient's habitual nearpoint distance, should have target (Vectogram 9). Line 4 is seen by the left eye, line 5 by both eyes,
and line 6 by the right eye.
a range of lenses from +1.50 to -2.00 D with clear
visin, with the normal response time being less than
5 seconds.
Chapter 2 47

TABLE 2-15. Partial List o Norms for Accommodatve Fadlity

Study Results Age Group

Burge39 2.00 D; 12 c/min monocular; 10 c/mirt binocular; 7 Children and young


c/min binocular, with supppesston belng monitored adults
37
Grffn et al. 2,00 D; 17 c/min monocular 2.00 D; 17 c/min Young adults
38
Griffin et al. monocular; 13 c/min binocular; 6 e/ min binocular, Young adufts
with suppression being monltored 1,50 D; 20 c/64
36
Lu et al. secs with 26 SO 2,00 D; 10 c/52 secs with 24 SD dulls
40 41
Grisham et al. and Pope et al, Children
SO = standard deviation.

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

as it s for saccades, pursuits, and position main-


tenance (discussed previously). TABLE 2-17. Ranking of Accommodative Stamina
If a patient meets the recommended criteria for
accommodative facility testing with a consistently Binocular
Monocular (secs)
good rate of responses throughout the test, there is Rartk Description
(secs)*
no need for stamina testing. 5 Very strong 2:108
Strong >60
84-108
4 Adequate 48-59
60-S3
Summary of Weak Very 36-47
3S-59 24-35
Accommodation Testing 3 weak <36 <24
Accommodative nsufficiency s tested n several
Note: Testing s at the rate of 6 secs/cycle (i.e., 3
ways. The amplitude of absoluta accommodation 2
secs per each corred responso) with 2.00-D tenses. The cutoff
s found by monocular push-ups and, possibly, by point s desig-nated as a response time exceeding 3 secs on any
bracketing between push-ups and push-aways 1 flip or whenever there is an incorrect response. *Suppression
lens
should be monitored using either anaglyphie or vectographic
when necessary. PRA and NRA are binocular tests targets when binocular testing is done.
of relativa accommodation. Dynamic retinoscopy
under binocular viewing conditions, conducted
with either the Nott or MEM method, determines
an accommodative naccuracy. tion) mus be taken nto account in visin therapy.
Testing for infacility introduces the element of These are discussed in relation to case examples
time, which relates to the efficiency of accommo- (along with the Maddox components) in Chapter 3
dative responsiveness. The standard testing proce- and also later n this book.
dure is to use 2.00-D lenses, first monocularly
and then binocularly. At least 10 cycles per minute Absolute Convergente
are necessary for monocular adequacy and 6
The total amount of convergence of the visual
cycles per minute binocularly (with suppression
axes (Unes of sight) from paral lesm at far to a
monitoring). Testing for ll-sustained accommoda-
bifixated target at near is called absoluta conver-
tion also involves the element of time. The differ-
gence, often also called "gross" convergence.
ence between this and testing for infacility is that
Absolute convergence may involve all four com-
the quality of accurate responses as to stability and
ponents of Maddox.
endurance is assessed, rather than the mere quan-
tity of accurate calis.
Testing Techniques
The clinical test for absolute convergence is per-
formed with a small target, traditionally a pencil
VERGENCES
tip, for measuring the nearpoint of convergence
Vergences are disjunctive eye movements (rather (NPC). The patient views a target in the midline as
than conjgate movements, as n the three other it s moved closer to the spectacle plae. Any
movement systems). The occipitomesencephalic object for fixation can be used, but a target requir-
neural pathway for vergences, at least for conver- ing accurate accommodation s recommended. A
gence, extends from rea 19 to the third nerve small isolated letter // E // ofapproximately 20/30
nuclei. Vergence movements are slow (as com- (6/9) size at 40 cm (1.5 minutes of are) has become
pared with saccades) and mainly involuntary. a clinicai standard. The examiner moves the target
According to the traditionally used Maddox classi- steadily at a rate of approximately 3-5 cm per sec-
fication, there are four components of conver- ond toward the bridge of the patient's nose. The
gence: tonic, accommodative, fusional (disparity), patient s asked to look at the letter and report
and proximal (psychic). Although authorities may when t first becomes blurred and then when it
disagree about whether this classification s the appears doubled. Despite blurring, some patients
only true classification, the consensus s that the may be able to maintain bifixation on the target all
Maddox concept is useful for clinical purposes. the way to the bridge of the nose (i.e., approximat-
Nevertheless, factors other than those considered ing the spectacle plae). Most patients, however,
in the Maddox classification (e.g., prism adapta-
50 Chapter 2

TABLE 2-78. Ranking of Resulte ofNearpoint of


be expressed in prism diopter (A) units. If, for exam-
Convergence Testing ple, the breakpoint is 7 cm from the spectacle plae,
the magnitude in prism diopters of absolute conver-
gence can be calculated trigonometrically. The follow-
ing formula, however, isconvenient for clinical purposes:
Recovery to 100
Breakpoint Singteness Prism diopters = IPD
Rank Descripton (cm) (crn)
X + 2.7
5 Verystrong 4 <5 5- <8 8-9
where IPD is the interpupillary
Strong 3 6 7-8* 10-11
distance. If, for example, the IPD is 60 mm (6 cm)
Adequate 2 9-15 12-18
and the NPC in breakpoint is 7 cm, then
Weak
1 Very weak >15 >18 A = 6 100 7 +
*A breakpornt distance more remote than 8 ctn s consldered 2.7
fallure, as is a recovery more remote than 11 cm.
A = 62

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

FIGURE 2-19Example of nearpoint-


of-convergence conversin from cen-
timeters to prism diopters. (E = fixation
target; IPD = interpupillary distance.)
Chapter2 51

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

visual acuity at far must be used for all baseline 5.


testing. TABLE 2-19. Ranking of Results of Negatve Relatve
When vergence ranges are tested with Risley Convergence Testing ai 6 m (Base-ln)
prisms, the speed of prism induction should be
standardized. If the rate s too slow, the patient
may have an excessive degree of prism adapta-
tion and may falsely pass the test. In contrast, if
the prism demand is ntroduced too rapidly, the Recoveryto
A
Rank DescriptionBreakpoint ( ) Singleness ()
patient may falsely fail the test. Most clinicians
5 Very strong 8 6
have found that the best overall rate of ntroduc-
tion of Risley prism power is approximately 4 A 4 Strong 7 5
per second. We recommend this rate for all slid- 3 Adequate 6 4
ing vergence testing, whether with Risley prisms, 2 Weak 5 3
Vectograms, anaglyphs, or targets n stereo- 1 Very weak 4 2
scopes. As Grisham 40 pointed out, "Test results
are markedly influenced by such procedural fac-
tors as speed and smoothness of prism power not necessarily clearness) is reported. A good
induction, amount of contour in the fixation tar- nstruction is, "Tell me when the double images
get, and phrasing of nstructions (i.e., Tell me join again into one."This endpoint is recorded for
when the target doubles,' as opposed to Try to the recovery valu.
keep the target single.')."
We recommend the following standard routine: Once the breakpoint and recovery vales for
NRC are recorded, these findings may be evalu-
1. Have the patient view a column of 20/20 ated n terms of their normalcy. Table 2-19 shows a
(6/6) letters (or the patient's minimum angle of res- ranking system whereby ranks of 2 or less are
olution f acuity is worse). abnormal and, thus, failing. Ranks of 3 or more are
2. Instruct the patient to try to keep the let passing. This ndicates that 6A break and 4A recov-
ters clear and report whether there is any blur ery are passing, which s n accord with Morgan's
ring. The Risley prisms are rotated symmetrically. norms (discussed n Chapter 3).
Note: Be skeptical if a blur is reported on Bl test Positive relative convergence (PRC) at 6 m s
ing at far. Blurring couid be due to an ncorrect tested in a manner similar to that used for NRC.
refractive status, such as latent hyperopia, or the The difference s that BO rather than Bl prism
patient may be over-minused. Therefore, it is vital demands are given. Unlike NRC at 6 m, a blur-
to perform vergence testing with the patient look- point usually s expected when BO prism demand
ing through CAMP lenses. The first sustained blur (PRC at 6 m) s ncreased. Some patients, how-
exceeding 2 seconds s recorded. Blurring should ever, do not report blurring, only breakpoint and
be that amount of degraded form acuity that recovery. We have found that with proper nstruc-
would be caused by +0.25-D overcorrection at 6 tion and demonstration, more than 90% of non-
m. Demnstrate this to the patient, if necessary, presbyopic patients are able to appreciate the
for reliable reporting for "blur." Again, blurring blurpoint at 6 m with BO prism demand. A blur-
should not normally occur with Bl prism testing at point of 7 A s "weak"; it should be at least 8 A
6 m. (Table 2-20). The breakpoint should be at least
3. Instruct the patient, "Try to keep the tar 1 6A, and recovery should be at least 9 A; other-
get single but tell me when the target doubles." wise, the cutoff criteria for passing are not met for
The first sustained diplopia is recorded. If the breakpoint and recovery.
patient reports a momentary diplopia that does
not exceed 5 seconds, that s disregarded. The Fusiona/ Vergences at Near
amount of prism causing a "sustained" diplopia The nearpoint testing procedure for fusional diver-
s recorded for "breakpoint." gence is similar to that at farpoint, except a blur-
4. After the endpoint of sustained diplopia is point is expected. It is known simply as NRC, the
reached, reduce the prismatic demand (at the rate 40-cm testing distance being implied. Ranking
of 4A per second) until sustained singleness (but standards are shown n Table 2-21. All nearpoint
testing of fusional divergence is conducted at 40
54 Chapter 2

TABLE 2-20. Ranking of Resulte of Positive Relative Convergence Testing at 6 m (Base-Out)

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).

TABLE 2-21. Ranking of Resulte of Negative Relative Reflex Fusin


Convergence Testing at 40 cm (Base-ln) Clinically, we recommend evaluating vergence
facility by direct observation. A small-power prism,
the vergence stimulus, is inserted in front of one
Rank Blurpoint Breakpoint Recovery to eye as the patient fixates a detailed target. The
Description {*) Singleness latency, velocity, accuracy, and stamina of vergence
responses can be directly observed and assessed.
5 Very strong >18 >26 >18 Without eye movement-recording equ-ipment,
4 Strong 14-18 22-26 14-18 these dynamic components cannot be quantified
3 Adequate 12-13 20-21 11-13
but, with practice, the clinician can make accurate
2 Weak 11 19 10 and valid judgments regarding the quality of reflex
1 Very weak <1 1 <19 <10 vergence function by closely noting the eye move-
ments stimulated by the prism. A virtue of this tech-
Chapter 2 55

TABLE2-22. Ranking of Resulte of Positiva Relativa Convergence Testing at 40 cm (Base-Out)

Rnk Description Blurpotnt (A) Breakpoint {A) Recovery to Singleness (A)

5 Very strong , >23 >28 >18


4 Strong 18-23 22-28 13-18
3 Adequate 15-17 19-21 8-11
2 Weak 14 18 7
<?
1 Very weak <14 <18

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

Study Fusfonal (Dlsparity) Vergence Fadlity (c/min) Comments

Kenyon et al.48 None in strabismks Also none in some amblyopc sub-


jects without strabsmus
Pierce49 8a Bl and 84 BO, 10 c/mln (median); screening Median for chtldren; 7.5 c/min rec-
criteron of 7.5 c/rnin ommended as cutoff for "nor-
mal" versus "learning-
disabled" childrert
8A B! and 8a BO, approx, 7 c/min S4 Bl Mean for sixth gradees
Styckle and Rouse50 and 8a BO, approx. 5 c/min 8* Bl and Mean for third gradees
Mitehell et al.51 8A BO, 6.53 c/min 8a Bl and 8&BO, Mean for sixth graders
5.05 c/min Mean for third graders {cutoff cr-
teron of 3 c/min recorr-
mended)
Moser and Atkinson52 8a Bl and 8A BO, 8.14 c/min Screening: 6 Young adults
Rosner53 Bl and 12ABO, 3 c/0.5 min 12A il and 14* At farpoint
BO 3 c/Q.5 min Goals At nearpoint
6* Bl and 1ZA BO, 18 c/1.5 min 12A B! and 14A
BO, 18 e/1.5 min 5A Bl and 15A BO in relation to At farpoSnt
the phoric posi-ton of each subject, 8,6 c/rmn At nearpoint
Jacobsow et al.54 Young adulto wth no visin prob-
54 Bl and 15A BO or 8A Bl and 8a BO lems; jump vergences wth two
seto of vectographtc targets
Delgadllo and Griffin55 Approximately same results (adult
subjects)
SI = base-in; BO = base-out

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

Rank Description Cycles per Minute


Rank Oescription Cycles per Minute
5
Very strong Strong Adequate 11-15 5 Very strong >90
Weak Very weak 5-10
4 4 Strong 66-90
fll - base-in; BO = base-out. 3-4
3 Adequate 30-65
3 Note: Suppression should be <3
monitored with anagJyphic or vec- 2 Weak 18-2&
tographic targets with targets equivalent to 20/30 being clear and 1 Very weak <19
single 2with each prisrn flip. The Vectographic SBde is recom-
rnended for 6 m, and Vectograms, as used for accommodative Bl = base-n; BO = base-out.
faclity, are recommended for testing at 40 cm. Note; Suppression should be m onftored as n vergence faelity
1
testing.

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):

Simultaneous perception (diplopia) Superimposition


Superimposition (first-degree fusin) The Superimposition of two dissimilar targets is
Fat fusin (second-degree fusin) known as first-degree fusin. However, when this
Stereopsis (third-degree fusin) occurs, confusin rather than true sensory fusin
exists, because similar targets are not being inte-
These categories of binocular sensory status can be grated; they merely have common oculocentric
conveniently tested by using vectographic tech- directions. Because two dissimilar objects stimu-
niques, colored filters, and the numerous stereo- late corresponding retinal points and are perceived
scopic methods employing septum arrangements. as superimposed, the definition of Superimposition
Many methods and instruments are presented in is satisfied.
this book, particularly in case examples. With the exception of the Maddox rod test,
Superimposition testing usually requires more
Simultaneous Perception instrumentation than a penlight in free space. Ste-
reoscopes containing a different target for each eye
Although Simultaneous perception is classified as
(e.g., a fish seen only by the left eye and a tank
one of the levis of sensory fusin, there is actually
seen by the right eye) are usually necessary (see
no real fusin with this particular binocular
Figure 5-6).
demand. Simultaneous perception is determined
to be present merely by the patient's awareness of
binocular images at the same time. In clinical Fat Fusin
usage, Simultaneous perception refers to the stimu- Fat fusin is true sensory fusin and is the integra-
lation of noncorresponding retinal points that give tion of two similar ocular images into a single per-
rise to diplopia. An example is shown in Figure 1- cept. There may be one target in free space, such
10, in which the fixated light is seen diplopically as a page of print, or there may be two identical
because the dioptric image is on a noncorrespond- targets in a stereoscope. In any event, to be classi-
ing point of the deviated right eye. fied as a flat-fusion stimulus, this type of target
The usual test applied in determining whether a must be two-dimensional and identical in form for
patient can appreciate Simultaneous perception is each eye.
to elicit a diplopic response when one object (e.g., Such targets are the most frequently employed
a penlight) is fixated. When deep suppression inter- in testing and evaluating motor fusin (fusiona!
feres with diplopia testing, stimulating a noncorre- divergence and convergence). Usually Snellen let-
sponding point somewhere outside the suppression ters or printed words are used as targets, to be
zone may be desirable. This is conveniently accom- fused with the incorporation of unfused suppres-
plished by placing a vertically oriented lose prism sion clues in the test design. (An example of a fat-
Chapter 2 59

fusin target with a test design for extrafoveal sup-


pression s shown in Figure 5-7.) If the angular sep- TABLE 2-26. Frequently Used Vectographic
aration from the center of the target to a Tests of Stereoacuty
suppression clue is greater than 5 degrees, testing
for peripheral suppression is being accomplished. Contoured (local Stereopsis) Stereo tests
Testing for foveal suppression requires that a sup- (Fly) (nearpoint testing) Stereo reindeer
pression clue be located in or near the center of test (nearpoint testing) Vectographic
the target. Therefore, the location of the clues that Slide (farpoint testing)
are suppressed determines the size of the suppres-
Noncontoured (global Stereopsis) Randot
sion. These specifications regarding targets for
stereotest (nearpoint testing) Random dot E
determination of suppression size are Usted in
stereotest (near to far testing)
Table 5-1.
In cases of heterophoria, however, foveal sup-
pression, rather than larger suppression zones
occurring in strabismus, is usually the concern.
Similarly, depth of suppression is necessarily eval- not fall exactly on corresponding retinal points.
uated n cases of strabismus but rarely s evaluated This is due to the allowance in disparity afforded
in heterophoria. (Testing for depth of suppression s by Panum's rea. It s this small fused disparity that
discussed in Chapter 5.) is responsible for Stereopsis.
As in flat-fusion testing, there are suppression
clues in Stereopsis testing, which are those portions
Stereopsis of the stereogram that are supposed to be seen in
Stereopsis is the perception of three-dimensional depth, relative to a fixated point. In the preceding
visual space due to binocular disparity clues. Test example, the clues are the fused lines. The lack of
targets for Stereopsis are similar to those for fat depth may be an indication of suppression.
fusin with one exception; n the former, there s
lateral displacement n certain portions of the tar- Vectographic Methods
get. The displacement of a set of paired points Applying the principie of poiarization to the testing
(referred to as homologous points) s relative to the of visin allows the use of suppression clues during
position of other pairs of homologous points on the fairly natural conditions of binocular viewing. For
stereogram. For example, n Figure 1-14, consider vectographic testing, the patient wears polarizing
the star as the figure that s fixated and fused. The filters in the form of spectacles. The polarizing filter
small vertical lines are displaced inwardly (BO, or for one eye must be rotated to an angle 90 degrees
crossed disparity effect) relative to the fused star. different from the filter for the other eye, thereby
Assume that the patient is concentrating on the achieving mutual exclusin of light coming to each
fused star. The vertical lines are maged on each eye. Thus, when the test targets are also polarized,
retina temporally in relation to the star, which one eye cannot see certain portions of the test target
causes the fused image of the lines to appear that are visible to the other eye. In the United States,
closer than the star. The opposite would be true if the filters n commercially available polarizing
the lines were disparately nasalward on each ret- spectacles usually are oriented at 45 and 135
ina. The rule to remember is that f the retinal dis- degrees; those manufactured in some other coun-
parity is temporalward ("templeward") from the tries are often set at 90 and 180 degrees.
center of each fovea, the stereoscopic image will Severa! frequently used vectographic tests for ste-
appear closer, whereas if the retinal disparity is reoacuity are usted in Table 2-26. Examples of vec-
nasalward, the image will appear farther. tographic tests are depicted in Figures 2-20 through
If the disparities become too far separated, the 2-24. Other nonvectographic tests (e.g., Frisby,
lines can no longer be fused (by remaining within Lang) are illustrated in Figures 2-25 and 2-26.
Panum's reas) and are seen diplopically. Because
they fall on points too disparate, they cause diplo- Linear Displacement Methods
pia in the same manner as n simultaneous percep- Stereoacuity may also be evaluated by comparing
tion testing. However, if the disparities are not very the relative distance of two objects in free space,
great, the targets are fusible even though they do such as n the traditional Howard-Dolman pe
60 Chapter 2

FIGURE 2-22Random dot E stereopsis test noncontoured targets.


(Courtesy Stereo Optical Co.)

FIGURE 2-20The "Fly" stereopsis test contoured targets. (Courtesy


Stereo Optical Co.)
tance of 6 m from the rods and s nstructed not to
move his or her head. Otherwise, lateral parallax
test, which s designed for farpoint measure- will be nduced, thereby nvalidating testing pro-
ments. The test consists of two black, movable cedures. The rods are moved by the patient, either
vertical rods viewed through an aperture against nearer or farther from each other, by means of
a white background. The patient is seated at a dis- strings, until they appear to be equidistant (i.e., n
the same plae). The distance error is determined
from an average of several triis and s converted
from millimeters nto seconds of are; this valu
represents stereoacuity (Table 2-27). For example,
Chapter 2 61
FIGURE 2-26Lang test. Images for the eyes are separated by the fine
FIGURE 2-25Frisby test. Random patterns are printed on each side parallel cylindrical strips to crate perception of stereopsis by way of
of a transparent pate. The patient s instructed to lcate in which of lateral displacement of images seen by each eye. Note that this is Lang
the four squares is the stereoscopically perceived circular target. test 1; another versin, Lang test 2, is also available.

if the error (the distance the patient misaiigns the


two pegs) is 60 mm, the stereoacuity is 20 sec-
onds of are. Because there may be a constant Stereoacutty
(seconds of are)
error due to a skewed or tilted horopter, however,
Alignment Error (mrn)
testing results may be invalid. The standard devia-
tion of the mean would represent a truer ndex of 5 2
stereoacuity, but acquiring this nformation would 10 3
require completion of approximately 15 triis; 20 7
henee, it seldom is done on a routine clinical 30 10
basis. An apparatus of the Howard-Dolman type 40 13
may be custom-made or obtained through com- 50 16
mercial sources. 60 20
For similar nearpoint testing, the Verhoeff Stere- 80 100 200 300 400 500 26
optor (formerly made by the American Optical 33
NatetAn taterpuptHary distance of 60 mm is
Corporation but no longer manufactured; see Appen- assumed, Stereoacuities were determined by 66
dix ]) has been widely used by many government the foHowing formula: T\ = IPD (x)/ef2 x 99
206,000, where i\ (eta) is the symbol for 132
agencies (e.g., military). It has an illuminated white stereoacuity in seconds of are; P0 is the
window in which three vertically placed black strips interpupillary distance n rnillime-ters; x is 165
are centered. One of the strips is displaced from the the alignment error in millimeters; and d is
the testing distance from patient to rods in rnillirneters.
plae of the other two, either forward or backward,
and the patient is asked to tell for which strip the
distance differs from the other two. The instrument
can be adjusted to form eight different strip arrange-
ments (i.e., eight different targets). A patient with a
stereoacuity of 31 seconds of are or better should be
able to report all eight targets correctly at a testing

TABLE 2-27. Howard-Dolman Test for Stereopsis,


Performed at 6 m
Chapter 2 63

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

STEREOACUITY AND LEVEL OF INDUCED


ANISOMETROPIA
CONTOURED TARGETS SEMICONTOURED TARGETS NONCONTOURED TARGETS

NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS 16 NUMBER OF SUBJECTS


16

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

LEVEL OF INDUCED ANISOMETROPIA LEVEL OF INDUCED ANISOMETROPIA LEVEL OF INDUCED ANISOMETROPIA


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

TABLE 2-30. Ranking of Resulte ofStereopss Testng (Seconds o Are)

Rank Deserlption Contouret Noncontoured

5 Very strong >20 >30


4 Strong 20-30 31-50
3 Adequate 3t-60 51-100
2 Weak 61-100 OI-iOO,
1 Very weak <100 <00

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

Tonic Convergente and Accommodative- Measurement 79


Convergence/Accommodation Ratio 70 Prescribing Prism 85 Validity of
Calculated Accommodative-Convergence/ Diagnostic Criteria 87 Recommendations
Accommodation Ratio 70 for Prism Prescription 90 Vergence
Gradient Accommodative-Convergence/ Anomalies 92
Accommodation Ratio 72 Zone of Convergence Insufficiency 93
Clear, Single Binocular Vision 72 Basic Exophoria 93
Morgan's Normative Analysis 76 Gritera Divergence Excess 94
for Lens and Prism Prescription 76 Divergence Insufficiency 94
Morgan's Expected Criterion 77 Basic Esophoria 95
Clinical Wisdom Criterion 77 Convergence Excess 95
Sheard's Criterion 77 Basic Orthophoria with Restricted Zone 96
Percival's Criterion 78 Normal Zone with Symptoms 96
Fixation Disparity Analysis 78 Bioengineering Model 97
Definition and Features 78

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

BASE IN Prora icol* ot 40 cm. ASE OUI 35 25


15 5 0 5 15 25 35 45 55 65 75 tS
i
tn. MO
j} q-i IEAK JO -
A-J ECOVEIW
to xn <OR1A 7.50

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

BASE IN 35 25 15 Prm col* o 40 o. M SfOUt


50 15 25 35 45 55
i m
1 i
1211 Ow*
109
D BUEAIC n VF
A tEOOVEXY
TW
8 xPHOSIA
Sft
76
I
/ y
t
9
54
/ /
s
32
/ j
3 /
1 / !
/ 1 2J
3
1 /
/ -u
*
X / 2

/! A.
A/ --AM
_/* /
// :
^IflB

FIGURE 3-2Phoria Une (salid


Une). The X marks represen! direct
measurements of the phoria.
20
IN
10 "
y 0

/
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

3-3Zone of clear, single binocular


visin. Vision is blurred outside the
enclosure.
74 Chapter 3

BASE IN Frisa MaUot 40 era. BASE OUT 35 35 15


S O S 15 25 35 4S 55 45 75 5

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

BASE IN Prm eoU ot 40 ere. 35 25 15 BASE ota


5 15 25 35 45 5. I 65 75 U
i 140
n O BLUK D
u 1HEAK
10 A RECOVEty -7 JO
XmOKIA
?
r *
8
.S
/ Si
/ /" / ^
7
s
|

3 /
/
/*
1 : / /
/ C
Ti
-4JO
*
43
/ : / / / f
0

21
a
E / /
: S 9
7IW
-USO

FIGURE 3-5Zone of clear, single


S /
/
V S

3
AJO

binocular visin showing charting of / V Ai^ / ^ ^


the negative relative accommodation /
X
/ f _i_n<ft

,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

6. Normally, there s no blurpoint for fusional divergence at far.


y sented
Thatbylimit
the amplitude
is between the phoria line
and the
ndicated by a breakpoint (diplopia). If a blurpoint s found, then the most likely Bl to blur line (divergence blur limit).
4
explanation is that the refractive error s not fully corrected with most Sheardplusemphasized
for the relation between the
hyperopia or is overcorrected with minus in a case of myopia. Suchphoria direction
blurring usuallyand the compensating fusional
indicates a spasm of accommodation. (disparity) vergence range. When discussing
Sheard's concept, the term reserve vergence
The horizontal limits are the same as were drawn previously n this example, but the
s used. For example, if there is an exophoria as
limits of relative accommodation are added (Figure 3-5). (Refer to Chapter 2 for
rep-resented n Figure 3-3, then positive
discussion of NRA and PRA.)
fusional reserve convergence s the distance
The clinically relevant features of the ZCSBV are the relations between its constituent
between the phoria and the opposing blurpoint.
parts (i.e., demand Une, phoria une, range of fusional vergence, and amplitude of relative
Similarly n an esophoric case, the negative
accommodation). Custom dictates specific ames for each of these features. PRC and
fusional reserve convergence s the distance
NRC are the ranges of fusional (disparity) vergence to the blurpoint that are measured
from the phoria line to the Bl to blur line. It is the
relative to the demand une (see Figure 3-3). These are the vales directly measured using the
relation between the phoria position and the
Risley prism vergence technique in both convergence and divergence direc-tions. Another
compensating vergence range that has clinical
way to describe the horizontal extent of the ZCSBV s to refer to the vergence ranges rela-
relevance according to Sheard.4 The
tive to the phoria line. Positive fusional convergence s the amount of convergence
significance and utility of these relations will be
measured between the phoria at any particular viewing distance to the BO blurpoint (or
discussed later.
breakpoint, if no blurpoint is found). Similarly, negative fusional convergence is repre-
Gross convergence (nearpoint of
convergence, or NPC) is not usually charted but
may be calcu-lated. A conversin formula
(centimeters to A) for clinical use is
Gross convergence (A) = IPD
100
Note that 2.7 is a correction factor for the
distance from the spectacle plae to the center
of rotation of the eyes.
For example: If the IPD = 60 mm and the
push-up NPC = 5 cm from the spectacle plae
(bridge of the nose), then A = 6 x (100/5 + 2.7) =
78A.
76

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

.MORGAN'S NORMATIVE ANALYSIS


Morgan, a principal founder of binocular visin case analysis, accumulated and analyzed clinical
phorometry data on 800 nonpresbyopic adults, ages 20-40 years.5 He established clinical norms for his
patient group, suggested expected vales for clinical evaluation (Table 3-2), and recommended using
one-half of a standard deviation from the mean to represent clinically suspicious findings. (These
expected vales are factors in the vergence clinical ranking system recommended in Chapter 2.) Morgan
also evaluated the pattern of clinical findings by determining correlation coefficients for various zone
components.6 His results are presented n Table 3-3. His important contribution demonstrated the
quantitative strength of these relations. Other findings also deserve interpretaron. For example, the
correlation between PRC and NRA was +0.5, a modrate correlation. A direct association exists between
these two features of the zone; the larger the PRC, the larger is the NRA. In many cases, accommodation
can limit vergence; conversely, vergence can limit accommodation. This relation
suggests the possibility of clinical syndromes, as Morgan astutely pointed out.
Morgan demonstrated that certain features of the ZCSBV tend to be congregated. Morgan's group A
findings are amplitude of accommodation, PRA, and NRC. Group B findings are NRA and PRC.
(Morgan also proposed another classification, group C, which includes the far and near phorias, the gra-
dient AC/A ratio, and the calculated AC/A ratio.) When group A findings are low, group B findings tend
to be high; Morgan refers to this case type as accommodative fatigue. The treatments of choice are
often a plus add for reading or visin training that would better balance A and B findings. When group
B data are found to be low and group A high, then the case type is referred to as convergence fatigue.
The recommended treatment would be either Bl prism to balance the two groups or fusional
convergence (BO) visin training.

GRITERA FOR LENS AND PRISM PRESCRIPTION


Many people have contributed to graphical case analysis over the years. Several researchers and cli-
nicians have recommended various criteria for the prescription of prisms and adds to balance various
elements with i n the ZCSBV. However, little research has been done to check the validity or reliability of
these criteria. Their clinical popularity has waxed and waned over the years, depending on the fash-
77

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

a. p --------------------SEEN BY O.D. ONLY


X - --------------- -SEEN BV BOTH O.D. AND ANQLE f
O.S.
!. ------ -SEEN BY O.S. ONLY VISUAL AXIS ORTHO

DEMAND UNE
POLARIZED TARGET
POLARIZED FILTERS

RGURE 3-6Illustrations of fixation


disparity. a. Target viewed by patient.
h. Theoretical posterior view of eyes C.
illustrating angle Fin exo fixation dis-
parity. c. Ratient's perception. (OD =
X
oculus dexter; OS = oculus sinister.) I O.S. lovra
O.D. fovea
POINT ZERO
PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)

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

SatadJn Near Point Balance Card Ver 1.0


Hold card at 16"(40cm) Mlehlgwi College of Optometry
HoldMaddoxrodbeforerighteye vttu FERRIS STATE UMIVERSITY

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

Orange Green , Green Orange

DISTANCE: 40 CM (1 6 INCHES) 25 CM (1 0 INCHES)


t F.D.(MIN.ARC) F.D. (MIN. ARC)
RED 0 0 0
1/2 4.3' 6.9'
GREEN 1 8.6' 13.7'
1-1/2 12.9' 20.6'
ORANGE 2 17.2' 27.5'
BLACK 3 25.8' 41.2'
BLACK 4 34.4' 55'
ESO F.D.: ARROW TOLEFT
ESO F.D.: ARROW TORIGHT

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

FIGURE 3-9Bernell Fixation Dis-


parity Test (a) oriented for horizontal
fixation disparity and (b) oriented for
vertical fixation disparity.
82 Chapter 3

I- SEEN BY O.D. SEEN BY O.S.


a. O e. --Oy
KSEEN BY O.S. SEEN BY O.D.

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.

RCURE 3-11Fixation disparity


curves plotting angle F as a function BASE-OUT
DEMAND(A)
plotted against horizontal prismatic
demand to vergence. a. Good ver-
gence ability in case of 8A exophoria. AT ZEROA (ORTHO)DEMAND
b. Poor vergence ability in case of 8A THE EXO FIXATION DISPARITY
IS 5 MINUTES OF ARC.
exophoria with Y intercept of 5 min-
utes of are (min are) exo fixation dis-
parity and X intercept of 6 A exo ASSOCIATED PHORIA OF6A EXO
fixation disparity. This graph could be (FIXATION DISPARITY 10'
applicable to available instruments NEUTRALIZED WITH 6A BASE-IN)
such as the Saladin Near Point Bal-
15"

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

shape and s considered to be the most prevalent,


found in approximately 60% of the population (64%
by Kwan et al.19). A type I curve having a steep slope
(crossing at the ortho demand position) often s asso-
ciated with visual symptoms. In these cases, visin
training often is successful in flattening the slope of
the curve while ncreasing fusional vergence ranges,
usually relieving symptoms due to vergence dysfunc-
tion. These cases have an excellent prognosis for
improvement. Type II and III curves have a fat seg-
ment that may or may not cross the x axis (see Figure
3-12). Type I! s often associated with esophoria
(although occasionally exophoria) and s the second
most prevalent type, found in approximately 25% of
the population. Type III, which s often associated
with exophoria (although occasionally with esopho-
ria), s found in approximately 10% of the popula-
tion. It should be noted that all FDCs should be FIGURE 3-12Four types of fixation disparity curves.

plotted from break to break (diplopia limits). A type I


FDC sometimes is incorrectly labeled as type II or III;
induced by lens stimulation that are analogous to,
this occurs when the examiner takes too few points
but not totaliy consistent with, the types found by
and fails to find a segment that crosses the x axis.
Ogle et al.,9 who used prism stimulation. They sug-
True types II and III often respond well to prism
gested that these lens-induced curves have diagnos-
prescription. Many type III cases that are exo fixa-
tic valun some cases. Furthermore, the lens
tion disparities can be treated with fusional conver-
power that reduces the near fixation disparity to
gence training. Type IV cases, the least prevalent
zero may help to determine the proper near pre-
(approximately 5%), have the worst prognosis for a
scription, particularly with prepresbyopic patients.
functional cure as compared with the other FDC
For example, if a +1.25-D addition lens reduces a
types. Figure 3-12 Ilstrales type IV exo fixation dis-
nearpoint eso fixation disparity to zero, this could
parity, but eso fixation disparity is also possible.
be the optimum prescription.
Individuis with this FDC type seem to adapt to
Although generating an FDC is recommended,
prism so that the fixation disparity cap never be
the clinician can get a general sense of whether the
neutralized. In other words, there may be no stable
FDC is normal or abnormal merely by measuring
XIN. Such binocular dysfunctions are not clearly
the associated phoria and evaluating the total range
understood. In type IV curves, sensory and motor
of fusional vergence. For example, f no fixation dis-
fusin disorders may be resistant to therapeutic
parity s induced over a relatively large range of Bl
attempts; the prism adaptation found during testing
and BO prism demand (e.g., 6A Bl and 9A BO at
s characteristic of many strabismic patients. Vision
near), then the clinician can assume the presence of
therapy s frequently ineffective in such cases.
a normal type I FDC. However, if eso fixation dis-
It is apparent that establishing the curve type and
parity and eso associated phoria are present with an
characteristics aids the clinician n making a diag-
ortho demand, the eso fixation disparity increases
nosis of a vergence dysfunction and points toward
with small amounts of Bl prism, and an exo fixation
certain therapeutic options. The clinician mus be
disparity s induced with relatively small amounts of
aware that the type of curve can change from far to
BO prism, then the clinician can visualize a steep
near fixation n many cases.9-20 It is mportant to
FDC. A three-dimensional model of fixation dispar-
evalate the FDC at the distance at which the
ity, vergence, and accommodation can also be con-
patient is experiencing binocular visin problems.
ceptualized (Figure 3-13).
Ogle et al.9 demonstrated that FDCs can also be
generated using lens additions to stimulate forced
vergence. By comparing the FDC found with prism Prescribing Prism
stimulation and that found with lens stimulation, a Two principal criteria have been recommended for
derived AC/A ratio can be computed. Building on the prescription of prism on the basis of fixation dis-
this work, Wick and Joubert21 found four FDC types parity: Sheedy's cterion22and the associated pho-
86 Chapter 3

FD at near

Demand Line

FD at far FAIR

POOR
Chapter 3 87

c.

Demand
Line

FD at f ar GOOD
FD at near

FIGURE 3-13Three-dimensional models of binocular visin showing the relations of accommodation, vergence, and fixation disparity (FD).
a. Indication of fairly good fusional vergences for clear, single, comfortable binocular visin, b. Poor fusional vergences indicating lack of good,
clear, single, comfortable binocular visin, c. Good fusional vergences ndicating excellent binocular status as to clarity and comfort.

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

in preference to no prism in esophoric subjects (par-


ticularly for farpoint viewing) and in presbyopic, TABLE 3-4. Ranking of Discrminatng Factors between
exophoric subjects. However, nonpresbyopic adults Symptomatc and Asymptomatic Subjects
with exophoria did not prefer the prism beyond a
chance level. Fortunately, visin training techniques Rank
Exophores Esophores
for ncreasing fusional convergence are very effec-
12 Sheard's criterion Y Phoria amount Fixation
tive in such cases.
ntercept
Payne et al.28 provided two sets of lenses to 10 3
disparity
patients with asthenopia and fixation disparity at 4
curve slope Recovery
X ntercept
near. The prism amount was determined by measur- range Break range
Vergence
ing the associated phoria using a nearpoint Mallett
opposing phoria Vergence opposing phoria
Unit, and a double-blind (masked) procedure was
Vergence recovery
employed. By this criterion, all patients (eight non- Source: Reprinted with
presbyopic exophores and two esophores) chose to permission from JE Sheedy, J Saladin. Validity of Diagnostic
keep the prism prescription. Grisham29 reported Crtena and Case Analysis in Binocular Vision Disorders. In:
Vfefgence fye Movements. CM Schor, KJ Ciuffreda, eds.
prism acceptance in a group of symptomatic pres- Boston: Butterworths; 1983:517-540.
byopic exophores using associated phoria as the
prism criterion. Of the 12 patients, 10 chose to keep
the prism that neutralized their fixation disparity at
near. On the basis of theoretical considerations, the FDC, the overall shape and type of the FDC
some clinicians do not believe in the use of associ- remains stable over time. This principie apparently
ated phoria alone for prism prescription. However, applies to the vertical FDC also. One study found
the preceding evidence suggests that this method that the shape of the vertical FDC (approximating a
has clinical utility, at least when determined by a straight Une) remains stable over time, whereas its
test that has a central fusin stimulus (i.e., "lock") slope varied significantly, more so over weeks and
for example, the Mallett unit, Bernell fixation dis- months than during the day.31
parity slide, or the Saladin Card. Variability in the FDC in patients with binocular
The three approaches just described for evaluating problems has not been adequately studied. There
the validity of graphical case analysis have all, in gen- are, however, ndications that symptomatic patients
eral, supported its clinical utility. However, any clini- with abnormal FDCs show increases in curve slope
cal analysis system based solely on subjective and magnitude of fixation disparity when reading
response indicators suffers from inherent limitations. for short periods.32 Yekta et al.33 found that a large
In coming to a particular diagnosis of a binocular fixation disparity (YIN) and associated phoria (XIN)
dysfunction, the clinician s advised to base judgment are related to visual symptoms n patients of all
on a pattern of findings rather than on any specific ages, ncluding presbyopes. They also reported that
attribute of the ZCSBV. Several clinical Gritera should by the end of a working day, there is a significant
be applied in case analysis when looking for a pat- increase in both of these ndices that correlates with
tern of responses indicative of a functional binocular increased asthenopic symptoms.34 Although more
visin dysfunction. Fixation disparity analysis is an studies are indicated, it appears that several
alternative system of evaluation that often s used in attributes of the FDC are clinically reliable and valid
addition to graphical analysis to establish the diagno- ndicators of vergence dysfunction.
sis and management of vergence disorders. Certain advantages and disadvantages are asso-
An evaluation of fixation disparity and the ciated with each particular clinical instrument
attributes of the FDC has become a popular mode used in the evaluation of fixation disparity. The
of vergence case analysis. Ogle et al. 9 initially Sheedy Disparometer, the Saladin Near Point Bal-
reported good reliability of fixation disparity mea- ance Card, or the Wesson Card can be used to plot
surements, and subsequent studies of the FDC n the FDC. Several features of the FDC have clinical
individuis having normal binocular visin indi- significance in identifying a vergence dysfunction,
cated only a small amount of measurement drift as reviewed previously. The FDC measured with a
over days and weeks.18'30 Although increases in Disparometer was shown to have acceptable con-
convergence or divergence fusional demand current validity with a laboratory horopter method
(prism demand) may result in some variability of
90 Chapter 3

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-

TABLE 3-5. Clinical Methods for Prescribing Prisms

Exophoria Esophoria Hyperphoria

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

This classification system usually s based on


angles of deviation measured by the altrnate
cover test, not phorometry. The angles of deviation
should be measured in an open-space environ-
ment. Instrument convergence and accommoda-
tion effects may invaldate the measurements of
tonic vergence and accommodative convergence.
Although the categories apply to cases of strabis-
mus as weli as heterophoria, the following discus-
sion of management recommendations is primarily
for cases of heterophoria. -2O -1O 10 20 30 40 50
CONVERGENCE (A)

Convergence Insufficiency FIGURE 3-14Convergence nsufficiency representad graphically.


Convergence insufficiency (Cl), or convergence Classic graphica! analysis, which is a two-dimensional model of
binocular visin in terms of the relation between accommodation
insufficiency exophoria as it is sometimes called, is
and vergence. (AC/A = accomodative-convergence/accomodation.)
characterized by a low AC/A ratio resulting in an
increased exophoria at near viewing distances
(Figure 3-14). A symptomatic patient showing
orthophoria at far and 5 A exophoria at 40 cm symptomatic presbyopic patients are untreated.
would be an example. Other clinical findings asso- This neglect is nappropriate. Two extensive studies
ciated with Cl include a reduced PRC, a reduced showed very positive outcomes with visin train-
NPC (poor gross convergence), and deficient ing.45'46 Further evidence was supplied by Grisham et
accommodative responses.44 Vision training is the al.29 who prescribed two pairs of bifocal specta-cles
treatment of choice for most Cl cases. There s to symptomatic presbyopic individuis with
abundant evidence in the literature that this s exophoria. One pair had a prism amount equal to
effective.44 Because the AC/A ratio is low, added the associated phoria at near and the other was
lenses (e.g., minus power) are of little valu. Prism identical except there was no prism. The individu-
prescriptions have the disadvantage in these Cl is wore the two pairs of spectacles alternately for 2
cases by inducing an esophoria at far. Sometimes t weeks and then had to return one pair. Of the 12
is advisable for patients presenting with accommo- subjects, 10 chose to keep the prism spectacles for
dative insufficiency and Cl to have a reading add reasons of visual comfort, a result that Ilstrales
together with Bl prism for nearpoint use only. our point. It was also found that the two individuis
However, these patients also respond well to who returned the prism spectacles were uncomfort-
visin training. Some Cl cases sometimes present abie because the prism, although helpful at near,
with a large exo deviation (low tonic convergence) had induced a significant esophoria at far. Those
at far, combined with a low AC/A ratio. These are two would have been better managed with single-
the cases that most likely benefit from a Bl prism vision reading lenses that included the Bl prism.
prescription (relieving the exo deviation at far) in
conjunction with visin training to improve
fusional convergence at near. Basic Exophoria
Another similar Cl case type, usually ignored in Basic exophoria refers to cases n which the tonic
most classification systems, is presbyopic exopho- position is exophoric at far and the AC/A ratio is
ria. Most aging presbyopes show increases in their normal. The far and near exo deviations are
exophoria at near. Often there is reduced PRC, and approximately equal in magnitude. An example
these patients develop classic symptoms of Cl (e.g., would be a symptomatic patient who presents with
tired eyes, sleepiness when reading, and avoidance 8A exophoria at 6 m and 8A exophoria at 40 cm
of near work). Unfortunately, most clinicians and (Figure 3-15). The basic exophoria patient may
the patients nterpret these symptoms as part of the experience visual symptoms at both far and near.
normal aging process. If a young person presented Much clinical literature indicates that significant
with typical Cl symptoms, visin training would exophoria is more prevalent in people experienc-
likely be recommended. We believe that many ing reading difficulties.47 Because fusional conver-
Chapter 3

_
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)

ing often takes several months, and there can be fre-


quent regression of fusional divergence skills. If the
BREAK
BECOVERT
PNOMA
Q
^
X
^
basic esophoria patient is symptomatic only at near
'S ^
due to work requirements (e.g., computer or desk
'K>U4>UiO>S|Ca|

work), a reading add (either single-vision lenses or


^^
* s >
^
bifocals) may also be considered. s. ^ ^.
------- ------- ------- &-^ : ___ a^L_.

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.

Basic Orthophoria with Normal Zone with Symptoms


Restricted Zone Schapero43 also discussed the case of symptoms
43
Schapero discussed restricted zone cases, which but no s/gns, in which a patient presents with
he described as basic ortho cases with restricted symptoms that sound uniquely binocular in nature
fusional vergences and patient-reported visual but clinical testing fails to find any component of
symptoms. Heterophoria may be present, but its the ZCSBV that is deficient by clinical standards
magnitude is insignificant at far and near. The (Figure 3-21). Accommodative and fusional ampli-
NRC or PRC or both are deficient, as can be the tudes are normal. No significant heterophoria is
NRA and PRA. Sometimes the entire zone is measured, and the NPC s within 8 cm of the
found to be restricted (Figure 3-20). These bridge of the nose. The clinician must search for
patients often report visual fatigue after prolonged other possibilities before concluding that the
detailed visual activity and intermittent blurring, patient has psychogenic problems (e.g., hysteria,
particularly when changing fixation distance. malingering, or emotional instability). Some ques-
Reduced accommodative amplitude and facility tions and recommendations follow: Is there either
are often found. The etiology usually is functional latent hyperopia or pseudomyopia? Presence of
in that the patient's visual demands surpass his or either condition can be assessed with cycloplegic
her physiologic oculomotor and fusional capabil- refraction. Is there a latent phoria? Testing for this
ities. It must be kept in mind that the same clini- condition is by prolonged occlusion. Is there poor
cal findings and visual symptoms can result from accommodation or vergence stamina? The patient
drug side effects and general health conditions should be tested at the end of the workday.
(similar to those affecting accommodation that To determine whether the symptoms are truly of
were discussed in Chapter 2). Carefully obtaining binocular origin, the patient should be instructed
a patient history is necessary for differential diag- to wear a patch over the nondominant eye on
nosis. There may also be refractive causes of a altrnate days and to keep a log of resulting symp-
restricted zone, such as uncorrected astigmatism, toms. If symptoms decrease, some type of binocu-
uncorrected anisometropia, and aniseikonia. lar dysfunction is indicated. If symptoms remain
Optical management is ndicated n these cases. the same or increase, then other causes must be

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

We believe it s expedient to evalate binocular Soulhern California College of Oplometry, Fullerlon,


visin using the techniques of classic case analysis Calif., 1972.
15. Sheedy JE. Fixalion disparily analysis of oculomotor
and visin efficiency analysis. If clinical findings
imbalance. Am J Optom Physiol Opt. 1980;57:623-639.
point to a dysfunction of accommodation, ver- 16. Franlz KA, Scharre JE. Comparison of Disparomeler fixa
gence, or their interactions, a complete fixation lion disparily curves as measured wilh and wilhoul the
disparity evaluation is recommended. With this phoropler. Optom Vis Sci. 1990;67:117-122.
baseline clinical data and the analysis procedures 17. Dillemore D, Crum J, Kirschen D. Comparison of fixation
disparily measuremenls oblained wilh Ihe Wesson Fixa
recommended n this chapter, we believe the clini-
lion Disparily Card and Ihe Sheedy Disparomeler. Optom
cian has sufficient tools for successful and efficient Vis Sci. 1993;70:414-420.
treatment of the vast majority of nonstrabismic bin- 18. CooperJ, FeldmanJ, Horn D, DibbleC. Reliabilily of fixa
ocular anomalies. In patients who do not respond lion disparity curves. Am J Optom Physiol Opt.
to visin therapy as expected, t is always prudent 1981;58:960-964.
to retest, re-evaluate, and reconsider other 19. Kwan LK, Lam AK, Kwan CK, Yeung PH. The characlerislics
of near prism induced fixalion disparily curve in Hong
approaches to visin therapy, including referral to Kong Chnese. Ophthalmic Physiol Opt. 1999;19:393-
other professionals when indicated. Flexibility n 400.
the clinical approach s another lesson to be 20. Wick B. Forced vergence fixalion disparily al dislance
learned from our new appreciation of the com- and near n an asymplomalic young adull populalion. Am
plexity of binocular visin nteractions, as sug- J Optom Physiol Opt. 1985;62:591-599.
21. Wick B, Jouberl C. Lens-induced fixalion disparily curves.
gested by bioengineering models.
Am i Optom Physiol Opt. 1988;65:606-612.
22. Sheedy JE. Aclual measuremenls of fixalion disparily and
ils use in diagnosis and Irealmenl. J Am Optom Assoc.
REFERENCES 1980;51:1079-1084.
1. Donders FC. On the Anomalies of Accommodation and 23. Morgan MW. Anomalies of Ihe Visual Neuromuscular
Refraction of the Eye, trans. Moore WD. London: The Syslem of Ihe Aging Patient and Their Correclion. In:
New Sydenham Society; 1864. Vision of the Aging Patient. Hirsch M, Wick R, eds. Phila
2. Morgan MW. The Maddox classification of vergence eye delphia: Chilln; 1960:125.
movements. Am J Optom Physiol Opt. 1980;57:537-539. 24. Saladin JJ. Phoromelry and Slereopsis. In: Borish's Clinical
3. Flom MC. Treatment of Binocular Anomalies of Vision. In: Refraction. Benjamn WJ, ed. Philadelphia: WB Saunders;
Vision of Children. Hirsch M, Wick R, eds. Philadelphia: 1998:729.
Chilln; 1963:216. 25. Grisham JD. The dynamics of fusional vergence eye
4. Sheard C. Ocular discomfort and its relief. EENT. movemenls in binocular dysfunction. Am J Optom Phys
1931;7. iol Opt. 1980;57:645-655.
5. Morgan MW. Analysis of clinical data. Am J Optom Arch 26. Sheedy JE, Saladin J. Validity of Diagnoslic Crileria and
Am Acad Optom. 1944;21:477-491. Case Analysis in Binocular Vision Disorders. In: Vergence
6. Morgan MW. Accommodation and convergence. Am J Eye Movements. Schor CM, Ciuffreda KJ, eds. Boslon:
Optom Arch Am Acad Optom. 1968;45:41 7-491. Bullerworlhs; 1983:517-540.
7. Sheedy JE, Saladin JJ. Phoria, vergence, and fixation dis 27. Worrell BE, Hirsch MJ, Morgan MW. An evalualion of
parity in oculomotor problems. Am J Optom Physiol Opt. prism prescribed by Sheard's crilerion. AmJ Optom Phys-
1977;54(7):474-478. iolOpt. 1971;48:373-376.
8. Percival AS. The Prescribing of Spectacles. Bristol, U.K.: 28. Payne CR, Grisham JD, Thomas KL. A clinical evalualion of
JohnWright; 1928. fixalion disparily. AmJ Optom Physiol Opt. 1974;1:88-90.
9. Ogle KN, Martens TG, Dyer JA. Oculomotor Imbalance 29. Grisham JD. Trealment of Binocular Dysfunclions. In:
in Binocular Vision and Fixation Disparity. Philadelphia: Vergence Eye Movements. Schor KM, Ciuffreda KJ, eds.
Lea & Febiger, 1967:145-151, 328-331. Boslon: Bullerworlhs; 1983:626-627.
10. Schor CM, Ciuffreda KJ, eds. Vergence Eye Movements: 30. Daum KM. The stability of Ihe fixalion disparity curve.
Basic and CHnical Aspects. London: Butterworths; Ophthalmic Physiol Opt. 1983;3:13-19.
1983:467. 31. Rulslein RP, Eskridge JB. Sludies in vertical fixalion dis
11. Mallett RFJ. The invstigation of heterophoria at near and a parily. AmJ Optom Physiol Opt. 1986;63:639-644.
new fixation disparity technique. Optician. 1964;148:547- 32. Garzia RP, Dyer G. Effecl of near-poinl slress on Ihe hori-
551. zonlal forced vergence fixalion disparily curve. Am J
12. Morgan MW. Anomalies of Binocular Vision. In: Vision of Optom Physiol Opt. 1986;63:901-907.
Children. Hirsch MJ, Wick RE, eds. Philadelphia: Chilln; 33. YeklaAA, Pickwell LD, JenkinsTCA. Binocular visin, age
1969:176. and symploms. Ophthalmic Physiol Opt. 1989;9:115-
13. Col RG, Boisvert RP. Effect of fixalion disparity on ste- 120.
reo-acuily. Am] Optom. 1974;51:206-213. 34. Yekla AA, Jenkins T, Pickwell D. The clinical assessmenl
14. Levin M, Sullan B. Unpublished snior sludent research of binocular visin before and afler a working day. Oph
study. On file in Ihe M.B. Kelchum Memorial Library, thalmic Physiol Opt. 1987;7:349-352.
chapter4 / Strabismus Testing

History 101 = Signs and Symptoms 121 -"


Time of Onset 102 Diplopia 121
Modeof Onset 102 Abnormal Head Posture 121 .
Duration of Strabismus 103 Subjective Testing 122 Single-
Previous Treatment 104 Object Method 122 Two-Obfect
Developmental History 104 Method 123 Frequency^f the
Summary of Clinical Questions 105 Deviation 126 Classifcation
Measurement of Strabismus 105 126 Evaluation 127 Patient
Direct Observation 105 History 127 Testing 127
Angle Kappa 105 Direction of the Deviation 128
Hirschberg Test 106 Classification 128 Obective
KrimskyTest 107 Testing 128 Subjective Testing
Unilateral Cover Test 107 129 Magnitude of the Deviation
Altrnate Cover Test 108 130 Classification 131 Testing
Four Base-Out Prism Test 109 Procedures 131
Brckner Test 110 Accommodative-Convergence/
Comitancy 110 Accommodation Ratio 132 Eye
Causes 110 taterality 132 Eye Dominancy
Criteria and Terminology 111 133 Variability of the Deviation
Primary and Secondary Deviations 112 133 Cosmesis 133
Ductions 113
Versions 115
Three-Step Method 115
Recording Noncomitant Deviations 118
Spatial Localizaron Testing 121

When the status of a patient's strabismus is evaluated, HISTORY


the first step is to make a diagnosis of the deviation.
Much nformation aboutthe strabismic deviation can Resides giving tentative determinaron for each of
be obtained by a careful case history. After that, the aforementioned variables, a patient history s
objective testing can verify nine mportant diagnostic needed to assess the time of onset of a manifest
variables: comitancy, frequency, direction, magni- deviation, its mode of onset, its duration, previous
tude, accommodative-convergence/accommodation treatment and results, and pertinent developmental
(AC/A) ratio, eye laterality, eye dominancy, variability, history that may have a bearing on the binocular
and cosmesis. status of the patient.
102 Chapter 4

Time of Onset time of onset is mportant in the prognosis for func-


A vital part of any strabismus diagnosis is to ascertain tonal cure, the clincian must differentiate infantile
whether the strabismus s congenital. More correctly, from later-acquired esotropa. When the history fails
congenital strabismus should be referred to as essen- to pnpoint the onset of esotropa, certain testing may
tial infantile strabismus because, in many such cases, indcate whether the esotropa was essential infantile
the manifest eye turn s not present at the time of or acquired: Some possble characteristics of essen-
birth. In cases of essential infantile strabismus, clini- tial infantle esotropa can be compared with those of
cal experience with visin therapy, including surgery, acquired esotropa (Table 4-1). These findings are
has shown that the prognosis for normal binocular useful when the patient history s insufficient. It also
visin s very poor unless treatment occurs very early. may be helpful to have parents bring early childhood
We believe that the age of 4 months is the critical photographs for nspection, partcularly those taken
cutoff between essential infantile and early acquired before the child reached the ages of 1 and 2 years.
strabismus, because by that time the accommodation The prevalence of essental infantle exotropia s
has developed to a large degree. The classification of lower than that of nfantile esotropa. Onset of
late acquired strabismus pertains to occurrence of acquired exotropia, however, may be early, often
strabismus beyond the age of 2 years. For example, before the age of 2 years.
an infant with intermittent esotropa at 6 months of
age may have an accommodative-convergence com-
ponent that results n the strabismus. For children 2 Mode of Onset
years of age and younger, parents should be ques- It is important to know whether the strabismus was
tioned to determine the specific month of onset. For intermittent or constant when t became apparent. An
example, an essential infantile esotropa at birth intermittent strabismus is relatively more notceable
probably has a poorer prognosis for cure with early than one of equal magnitude that s constant and
treatment (e.g., surgery before age 2 years) than if the unchanging. Although an intermittent strabismus may
onset were at 4 months of age. In the latter case, the cause cosmetic concern, t has a less deieterious
nfant has presumably experienced 4 months of corti- effect on binocular function than does constant stra-
cal development for binocular visin. bismus. Even f treatment were delayed, t can be
To ascertain the time of onset, a complete report assumed that the child with an ntermittent manifest
of previous professional examinations should be deviation did not completely lose central binocular
obtained. However, this is not always possible and fusin, as would happen n constant strabismus. This
information from parents, relatives, and friends is is a particularly important point for consideraron n
often erroneous. Pseudostrabismus can be confused cases of small-angle esotropa with a monofixation
with true strabismus; the appearance of esotropa pattern. Even though the eyes are apparently straight,
can be simulated by epcanthal folds, negative-angle a small constant esotropa may be present. Only
kappa, narrow nterpupillary distance, and other when peripheral fusin breaks down and the larger
cosmetic factors. Any of these factors can cause par- eso component is manifest will the esotropa be cos-
ents to beleve that their baby has esotropa, when n metically notceable. This seemngly ntermittent
fact there s only pseudostrabsmus. Further confu- esotropa s, nevertheless, constant.
sin as to time of onset s introduced when a pseu- Exotropia, on the other hand, tends to be either
dostrabismus later becomes an acquired strabismus. purely intermittent or constant; the deviating eye s
A patent history obtained from the parents s not likely to be either all the way out or all the way
always reliable for accurate tming of the onset. Par- aligned for bifoveal fxation. Mode of onset reported
ents can also be msled by the poorly coordinated in the history s usually more relable n cases of
eye movements usually present n the early postnatal exotropia than n esotropa. Early acquired exo
period, which can cause a report of congenital stra- deviations tend to be intermittent as compared with
bismus when, n fact, the infant's binocular status eso deviatons, which tend to have a sudden con-
was normal with respect to age. stant mode of onset. Typcally, an ntermittent exo
We believe the prevalence of infantile esotropa is devation that begins at approximately 2 years of
approximately 25% of all cases of constant esotropa. age contines to be ntermittent for many months.
In the majority of esotropes (whether constant or Frequently, intermittent exotropia n young children
intermttent), onset is after the age of 4 months and gradually becomes more frequent and may become
usual ly before 6 years but occasionally later. Because constant over time, unless visin therapy s insti-
Chapter 4 103

TABLE 4-1. General Guidelines for Characteristics That Might Differentiate between Essental Infantile
and Later-Acquired Esotropa

Essential Infantile Esotropa (birth^4 mos) Aequired 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

observed in all cases. It is very unwise just to let


TABLE 4-2. Information to Obtain from Patents with a things be, as valuable time is lost. For instance, a
History of Extraocular Muscle Surge/y case in which the onset is early and there is con-
stant unilateral esotropa, altrnate occlusion
might be prescribed as a measure for preventing
Age when surgery performed
amblyopia. Also, base-out (BO) prisms (e.g.,
Eye undergoing operation
Fresnels) should be considered as a holding action,
Right
particularly if the patient is below the orthoptic
Left
training age (younger than 4 years). In certain
Both
cases, the use of BO prisms may be undertaken in
Muscle(s) undergoing operation
conjunction with plus-lens therapy. If good binoc-
Technique (e.g., recession, resecton)
ularity cannot be recovered after a reasonable
Cosmetic appearance
period, extraocular muscle surgery may be the rec-
Preoperatively
ommended treatment.
Immediately postoperatively
Later postoperatively Functional result (much
depending on professional Previous Treatment
reports) Repeat precedng information for additional After questioning regarding time, mode, and dura-
surgeries tion of onset has been completed, another important
fact to determine from the patient history is the
extent and type of previous treatment that the patient
has actually received. However, treatment all too
primarily in those children with a short duration often is recommended but not sufficiently under-
between onset of strabismus and surgical interven- taken. Treatment usually takes the form of patching
tion. Clinical experience indicates that several an eye, but in many cases it is found to have been
months without bifoveal fusin can cause irrepara- inadequate. The lack of proper occlusion therapy
ble loss of central fusin to the infant or very young impedes recovery; in addition, a history of a patient's
child if treatment is delayed. When the duration is having been patched can lead to erroneous conclu-
inordinately long and visin therapy is delayed, sions on the part of a subsequent examining clini-
peripheral fusin may also be irrecoverable. cian. The second doctor may mistakenly conclude
The duration time factor is not as critica! in the that everything possible was done for the patient and
ages beyond the developmental years as it is in the that any existing amblyopia cannot be eliminated by
plstic years below the age of 6. Nevertheless, loss means of patching, as such therapy has been tried
of the faculty of bifoveal fixation is not uncommon without success. To avoid such incorrect assump-
in adults who have had to give up bifoveal fixation tions, questions regarding previous treatment must
over a long period for one reason or another (e.g., be pursued in depth. This rule applies not only to
unilateral cataract of long standing, acquired stra- occlusion therapy but to any of the other various
bismus of many years due to paresis). It is not forms of treatment for binocular anomalies. Table
always possible to regain bifoveal fusin, even 4-2 lists information that should be obtained when a
though the obstacles may cease to exist (e.g., good patient has undergone extraocular muscle surgery.
visual acuity after a cataract operation).
Total duration (time of onset to patient's current
age) and the time elapsing from onset to treatment Developmental History
must be differentiated. Although both time periods The purpose of obtaining a developmental history
are important determinants in prognosis for func- is to determine the important milestones at differ-
tional cure, the period between the time of onset ent ages in a child's Ufe. Of interest are the physi-
and the beginning of treatment is usually more cal, mental, and emotional development of the
important. If effective therapy is wisely and imme- individual mainly in the plstic years before age 6.
diately instituted, the chance for recovery of binoc- A developmental history may explain why a
ularity is greater than if treatment is delayed. This is patient has a particular binocular anomaly.
not meant to imply that treatment (e.g., surgery) Fisher1 stated that gross neurologic dysfunction
should be performed instantly and with reckless has been found in almost 25% of patients with infan-
abandon; rather, caution and discretion should be tile esotropa. In contrast, the prevalence of such
Chapter 4 105

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

i was the eye tyrn frst noticed? titn


inward or outward turning? tit just one Oirect observation
eye, or did either eye turn? Hirschberg test Krtmsky
eye turned, what percentage of time did the t test Four base-out prsm
eye turn, and what percentage did the teft turn? test Unilateral cover test
; turning take place atl the time or just some of Brckner test
time?
! turning was just some of the time, how often ft?
i any particular time or actvity that caused > they are cosmetically noticeable n most cases.
eye turn?
Deviations of less than 10A usually are not detect-
i eye turn gotten worse, more f requent, or r?
able by direct observation alone. Moderately sized
Itreatment was given, and what were the
angles may or may not be noticeable, depending on
s?tare the cosmetic toncerns, symptoms, or
other factors such as angle kappa and epicanthal
other
folds. A great problem with reliance on direct obser-
vation is that pseudostrabismus often is confused
with true strabismus by this method. More sensitive
testing s required, such as the Hirschberg test,
ing anomaiies is low n cases of acquired which involves evaluation of angle kappa.
>ia. Henee, a history of neurologic signs
may i infantile strabismus. A mild lag in
neurologic nent may produce detrimental Angle Kappa
factors n the lent of good binocularity. A Angle kappa s the angle between the visual axis and
developmental ' can be important in many the pupillary axis. It s practically the same as angle
cases of strabismus. alpha, which is the angle formed at the first nodal
point by the intersection of the optic axis and the
visual axis. Because angle alpha cannot be measured
rniary of Clinical Questions
by clinical means, angle kappa is the traditionally des-
4-3 outlines sample questions on a typical il
ignated clinical term, although technically the clini-
form for the purpose of strabismus diagno-
cian is measuring angle lambda (the angle subtended
Each of these questions can be explored n
at the center of the entrance pupii of the eye by the
but the basic format s similar n most cases i
intersection of the pupillary axis and the visual axis).
strabismus testing s begun.
The magnitude of angle kappa (actually lambda)
customarily is referred to in terms of millimeters
UREMENT OF STRABISMUS rather than prism diopters (A) or degrees. Although
the normally expected magnitude s from 0.25 mm
il methods may be used for detection of strabis-Some positive (nasalward) to 0.5 mm positive, there s
are more sensitive than others, meaning tdetection is nothing abnormal about a larger or smaller angle
more likely using those methods. For ampie, the kappa (even a negative, or temporalward, angle)
unilateral cover test s more likely to strabismus provided the magnitude is the same for each eye.
than s direct observation. Objec- methods are The distance in millimeters between the corneal
Usted in Table 4-4, and the relative 9BBtvity for reflection of the fixated penlight and the center of
detection of each is shown. the pupil determines the magnitude (Figure 4-1).
Testing is performed monocularly under dim room
Observation illumination. The patient fixates a penlight at a dis-
Horizontal manifest deviations greater than 20A can tance of approximately 50 cm. The examiner's sight-
be detected by observation alone, because ing eye must be directly behind the light source. The
position of the corneal light reflection n relation to
106 Chapter 4

Hirschberg attempted to quantify the strabismic


FIXATION
PUPILLARY
angle by comparing the first Purkinje image (clini-
LIGHT cally referred to as the corneal reflex), located in the
K! AXIS
entrance pupil of the fixating eye, with the apparent
location of the corneal reflex on the deviating eye.
O.D. Because the cornea acts as a small convex mirror, a
virtual image of the bulb of the penlight is formed.
The reference points for judging the position of the
reflection on the strabismic eye include the center
of the pupil, the pupillary margin, and the limbus. In
the past, guidelines for quantification were used:
For example, a reflex appearing to be on the tempo-
ral limbus of the deviating eye was estimated to rep-
resent 100A of esotropa. This method is not reliable,
b. because factors of corneal size, corneal steepness,
O.S.
OCCLUDED and angle kappa must be taken into account for
accurate measurement.
FIGURE 4-1Illustrations of angle kappa (K). a. Top view of right eye, Various clinicians have proposed simple ratios
illustrating a positive angle kappa. b. Front view of right eye, illustrating a for measuring the magnitude of strabismic devia-
positive angle kappa. The light reflection is displaced nasally by approxi- tions. In the past, the commonly accepted ratio
mately 1 mm. (f = fovea; O.D. = oculus dexter; O.S. = oculus sinister.)
was 12A per 1-mm displacement of the reflex of
the deviating eye, relative to its location on the fix-
ating eye. A much higher ratio of 22A/mm was pro-
the center of the pupil is observed and estimated. For posed by Jones and Eskridge.3 Griffin and Boyer4
example, a finding of 1 mm nasal is expressed as 1 used photographic means to study subjects with
mm positive angle kappa for the eye (+1 mm). The known magnitudes of strabismus. The position of
same procedure is repeated for the other eye. The each corneal reflex in the photographs was deter-
usual causes of an observable difference in angle mined by microscopical analysis.Their results con-
kappa between the two eyes are (1) large eccentric curred closely with those of Jones and Eskridge.3
fixation of an eye; (2) a displaced pupil (corectopia); Studies in children indcate that the ratio of 20-22
and (3) a displaced fovea (macular ectopia). mm is essentially stable throughout development,
except at ages younger than 5 months.5'6 For clini-
Hirschberg Test cal purposes, the same ratio can be used for chil-
In the latter part of the nineteenth century, Julius dren and adults.
Hirschberg2 introduced a quick and practical test Interpretation of the Hirschberg test is illustrated in
for measuring the angle of strabismus. The proce- Figure 4-2 in which a 22/1 ratio is assumed and the
dure has remained the same over the years, pupil size is 4 mm. In Figure 4-2a and 4-2b, angle
although interpretation has varied. The Hirschberg kappa (more correctly, angle lambda) is zero. In Fig-
test is performed by directing a small light source, ure 4-2c and 4-2d angle kappa is +1 mm, and in Fig-
such as a penlight (Hirschberg used a candle ure 4-2e angle kappa is -1 mm. The importance of
fame), onto the patient's eyes. From behind the accounting for angle kappa for Hirschberg testing is
light, the examiner sights the eyes while the patient evident in these illustrations. Angle kappa is normally
is fixating the light. The examiner's dominant eye for between +0.5 and +1.0 mm, and a zero angle kappa
sighting is directly behind the light, preferably less is the exception. Therefore, the center of the pupil
than 10 cm from the light source. Hirschberg rec- and the corneal light reflection usually are not in
ommended approximately a 30-cm distance conjunction; rather, the reflex usually is displaced
between the light and the patient, although this may nasalward from the center of the pupil.
be increased to 1 m and still maintain accuracy. We The sensitivity of the Hirschberg test is limited to
recommend a range between 0.5 and 1.0 m for approximately 5A for horizontal deviations.7 A conve-
clinically measuring an angle of strabismus. nient clinical ratio is 20A/mm, which means that a
relative displacement of 0.25 mm of the corneal
reflex on the deviating eye represents 5A. This is the
Chapter 4 107

O.D. O.S.

a.

b.

FIGURE 4-3Unilateral cover test n an example of esophoria. A


translucent cover paddie (as depicted here) may be used for observa-
tion of the eye behind the occluder; if an opaque occluder is used, the
examiner can look around the paddie to observe the occluded eye.

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 4-5Examiner's view of eye movements on the unilateral


cover test when the occluder s placed before the fixating left eye. If
an opaque occluder is used, the examiner must look behind the
occluder to see the movement of the covered eye.

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 pitfall of the cover test is that its validity s vit-


ated f there s eccentric fixation. (Refer to the dis-
s switched to the left eye, the right eye takes up fix- cussion on eccentric fixation n Chapter 5.) For
ation, which causes a conjgate eye movement to example, suppose the patient has nasal eccentric
the patient's right-hand side. fixation of 5A of the right eye and has an esotropa
The next step is to switch the occiuder to the of the right eye of 5A. The measured magnitude on
right eye and place a prism between the eye and the cover test would be zero. If, in another case,
the occiuder. Then the occiuder is switched to the the true angle of esotropa s 8A, the cover test
left eye, and any conjgate movement is noted; f would yield a magnitude of 3 A of eso deviation.
there s no movement, the prismatic power repre- Eskridge7 proposed rules to differentiate between
sents the magnitude of the deviation (Figure 4-6). If the measured and true deviation. Nasal eccentric
there is an "against" motion, the BO neutralizing fixation causes the measured angle Hto be smaller
prismatic power is nsufficient, with a residual eso than the true angle H in esotropa but larger than
deviation. If there s a "with" motion, the prismatic the true angle H n exotropia. In contrast, temporal
power s overcorrecting the eso deviation (as eccentric fxation causes the measured angle H to
though the patient has an exo deviation). be larger n esotropa but smaller in exotropia
(Table 4-5).
F
i
x
a
t
a i
l o
n
E
c
c
e
n
t
r
i
c
Chapter 4

frequent exceptions to this rule. Pigmentary differ-


ence, unequal pupil size, and anisometropia inval-
date the Brckner test: That is, the fixating eye may
appear brighter than the deviating eye in such cases.
Nevertheless, the Brckner test s a good adjunct
method for detecting microstrabismus.

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

vascular problems, such as s not misleadingly overused. For clinical


hemorrhages, aneu-rysms, and purposes, the allowable amount of change of devi-
A
embolisms in older patients. Infectious aton is 5 , thus providing for the deviation to be
diseases that affect the central nervous dassified as comitant. If the change in deviation in
system also are frequent causes and any of the various positions of gaze s greater than
a
should be suspected, par-ticularly in 5 , the deviation s considered to be noncomitant.
young patients. The severity of noncomitancy can be evaluated by
Overactions may be due to applying the following qualifications:
mechanical anoma-lies, such as a faulty A
Mild: 6-10 change n deviation Modrate:
muscle insertion giving mechanical A A
11-15 change in deviation Marked: 16 or
advantage to the particular muscle.
larger change in deviation
More often, however, the overaction
can be explained by Her-ing's law of TABLE 4-6. Yoked Muscles
equal innervation to two yoked muscles.
This law states that the contralateral
synergists are equally innervated when
a movement s executed by both eyes. A noncomitant deviation of the visual axes may or
If, for example, the right lateral rectus may not be paretic. Paresis s an etiologic term,
muscle is paretic and requires an whereas noncomitancy is a descriptive term. Unless
abnormally high level of innervation to the etiology is known with absolute certainty, it is
abduct the right eye, the equally high wise to avoid using the word paresis or similar terms
level of innervation is sentto the medial such as palsy or paralysis, because noncomitancy
rectus of the left eye (the yoke muscle can also be due to a mechanical problem, such as
of the lateral rectus of the right eye) restriction due to faulty muscle insertion. When the
(Table 4-6). This results in an overaction etiology s uncertain, it s best to describe the condi-
of the left medial rectus, which further tion as noncomitant or to use a synonymous term
increases an eso deviation due to the (e.g., incomitant) until the exact cause is established.
paretic right lateral rectus. If this The term paresis is used n this text rather than
overaction contines for several months, paralysis. Although these words are used synony-
a permanent state of contracture may mously in the literature, paralysis seemingly
result, whereby the tissues of the left denotes total loss of function, although loss of
medial rectus eventu-ally become function may not always be complete. If there is
fibrotic and nonelastic. This worsens the total loss of muscle function due to nerve lesions,
prognosis for cure of an eso deviation. paralysis would be an appropriate term; this condi-
In this example of a paretic right lateral tion may also be called complete paresis. As a
rectus muscle, the right medial rectus rule, when the totality of loss of function is n
(homolateral antagonist) can also doubt, paresis is probably the preferred term.
become spastic and, eventually, fibrotic. In testing for noncomitancy, it s important to know
Precautions and appropriate therapy in the relationship of the visual axis of one eye to that of
such cases are discussed in Chapter 15. the other. If the axes (lines of sight) are parallel, the
eyes are postured in the ortho position. Figure 4-10
Criteria and Terminology illustrates parallelism with the eyes in the primary
position of gaze. Similarly, Figure 4-11 shows the
Few individuis have perfect
eyes n the orthophoric posture in the secondary
comitancy in the strictest sense, if the
position of gaze of dextroversion, in which each eye
term is used to mean that the angle of
made an equal movement to the right so that the
deviation remains exactly the same
orthophoric posture was maintained. Another helpful
throughout al I positions of gaze. The
way of illustrating eye posture is by showing a con-
frequent lack operfect comitancy
frontation view. Nine diagnostic positions of gaze are
occurs because the basic deviation of
demonstrated in Figure 4-12. These llustrations
most individuis vares slightly from
depict a patient's eyes in the orthophoric posture as
one direction of gaze to another.
seen by the examiner.
Therefore, some allowance must be
made so that the term noncom-kance
112 Chapter 4

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

a. Dextrosupraverston (Tertiary) c. Levosupraversion (Tertiary)


b. Supraversion (Secondary)

d. Dextroversion (Secondary) e. Primary Position


<JE>
f. Levoversion (Secondary)

g. Dextroinfraversion (Tertiary) h. Intraversin (Secondary)


O i. Levoinfraversion (Tertiary)

FIGURE 4-12The nine diagnostic positions (a-i) of gaze for conjgate eye movements, with secondary and tertiary positions indicated.

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.

FIGURE 4-14Directobservation of esotropa


of the rght eyeon dextroversion due to insufficent abduction; the left
eye is fixating. (O.D. = oculus dexter; O.S. = oculus sinister.)

FIGURE 4-15Hirschberg test in primary gaze and dextroversion.


FIGURE 4-13Esotropa of the right eye on dextroversion (right gaze). a. Ortho posture n the primary position of gaze. b. Esotropa of the
(f = fovea; H = magnitude of the horizontal angle of strabismus.) right eye n rght gaze.
114 Chapter 4

TABLE 4-7. Classification of Ductions and


Vergences

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

testing point. To test the ntegrity of the right lateral


rectus muscle, for example, the left eye is occluded
while the patient fixates a target with the right eye in
right gaze. To test the right superior oblique muscle
in its DAF, the patient's right eye fixates a target that
is to the left and down. Any underaction indicates a
restriction, possibly due to paresis.
Distinguishing between a true paresis and a
mechanical, or anatomic, problem is often diffi-
cult. In many cases, this distinction can be ascer-
tained by a good patient history in combination
with results obtained from the various methods of
testing and careful observation during duction
evaluation. The saccadic velocities test can help to
make this distinction. The clinician observes the
Excessive saccadic speed of the strabismic eye as it moves
Innervation toward and away from the restricted field. If the
toLMR
saccadic speed is approximately equal in both
directions before the eye enters the restricted field,
FIGURE 4-17Esotropa of the left eye is llustrated in a case of pare- a mechanical etiology is suggested. However, if
sis of the right lateral rectus muscle when the right eye is fixating. This
is the secondary angle of deviation, which is much larger than the pri-
saccades are slower when moving toward the
mary angle. (f = fovea; LMR = left medial rectus muscle.) restricted field, a paresis can be suspected.
Chapter 4 115

TABLE 4-8. Dagnostic Action Field of Each Extraocular Msele

Right Eye Muscle Gaze Left Eye Muscle Gaze

Right lateral rectus Right Left lateral rectus Left


Right medial rectus Left Left medial rectus Right :
Right superior rectus Right and up Left superior rectus Left and up
Right inferior rectus Right and down Left inferior rectus Left ard down
Right superior oblique Left and down Left superior oblque Right and down
Right inferior oblique Left and up Left inferior oblique Right and up

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

^ Right or Left Hyper -; Hyper Deviation Greater


Beviated Eye in Mrnary on Efther Right or Left Hyper Deviatton Greatest
Posltton Gaze on Either Right or Left Tilt Paretic Muscle
R R R Left inferior oblique

R R L Right inferior rectus


R L R Right superior oblique
R L L Left superior rectus
L R R Right superior rectus
L R L Left superior oblique
L L R Left inferior rectus
L L L Right inferior oblique
L= left R=right

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

is best accomplished by both the examiner and


the patient tilting their heads in the same direc-
tion (e.g., simultaneously toward patient's right
shoulder and toward doctor's left shoulder). In
this orientation, the altrnate cover test with
prisms can be performed as though both the doc-
tor and patient were facing each other with their
heads n the upright position. A small fixation light
<i testing s done at near) may be held by either the
patient or an assistant, as the doctor may require
both hands to hold the occluder and lose prisms.
The tip of the doctor's nose is also a convenient
and satisfactory target for this purpose.
In the case of a right superior oblique paresis, the
hyper deviation increases with a right head tilt,
bcause postural reflexes cause compensatory tor-
sional eye movements. (With a right head tilt, the
right eye must make an incycloduction movement;
that is, the top of the eyeball must move nasally
around its anteroposterior axis.) At the same time, the
left eye must make an excycloduction movement.
The impulse to keep the visual fields upright s com-
pelling, which explains why the head tilt test s defin-
itive in so many cases. In the case of a right superior
oblique paresis, the other ntorsion musclethe right
superior rectusis engaged to help ncycloduct the
eye. The action of this elevating muscle s the princi-
FIGURE 4-18The three-step method for diagnosing an isolated
pal reason for the ncreased right hyper deviation paretic cyclovertical muscle. The right superior oblique muscle s
with a right head tilt. Another reason nvolves the fel- affected in this example. a. Right hypertropia in the primary position.
low eye: The left inferior rectus s the yoke muscle of b. Hypertropia increases in left gaze. c. Further increase of the hyper-
tropia when head is tilted toward patient's right shoulder. Arrows ind-
the right superior oblique. Bcause of Hering's law, a cate direction of compensatory torsional movements.
hypo deviation of the left eye is produced, making
the right eye relatively more hyper deviated.
The responses of the other cyclovertical muscles A convenient analysis system for the three-step
on the Bielschowsky head-tilt test can be analyzed method s llustrated n Figures 4-19 through 4-22.
similarly by accounting for the torsional action of This visual portrayal conforms to the flowchart n
each muscle. The rule to remember s that a superior Table 4-9.
muscle rotates the eye nwardly (intorsion), and an Bajandas13 suggested adding a fourth procedure
inferior one rotates the eye outwardly (extorsin). The to the three-step method, which nvolves having
mnemomc expression "inferior people extort" may the patient look n upward and downward posi-
help one to remember the torsional actions of the tions of gaze. If there are questionable results and
eight cyclovertical muscles. For clinical purposes, the a clear differential diagnosis cannot be made
four lateral recti have no significant torsional action. between, for example, a right superior oblique and
The chief advantage of the three-step method is a left superior rectus muscle, the downward gaze
that it is an objective means of testing that requires will tend to ncrease the right hyper deviation and,
little participaron by the patient, other than fixat- thus, implcate the right superior oblique. Con-
ing a target and tilting the head. If the patient has a versely, an ncreasing vertical deviation on upward
hypertropia large enough to be noticeable, direct gaze would implcate the left superior rectus. Simi-
observation (with or without Hirschberg testing) lar reasoning applies for the other cyclovertical
may be all that is required. If either the deviation s muscles when applying this fourth step.
latent (phoric) or the hypertropia is too small to Bcause many cases of noncomitancy tend to
discern, the altrnate cover test is used. evolve toward comitancy (often referred to clinically
118 Chapter 4

Primarv Position: RE Hyper Primarv Position: RE Hyper

RIO (LIO LSR } RSR RIO m LSR

RSR

O RSO LSO LIR

RSO LSO LIR

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

Mead Tilt: Hyper Increases on Right Tilt


Hyper Increases on Left Tilt

LIO

LI

differ-entiating in cases of long duration. Also,


FIGURE 4-19A convenient analysis system for identifying an isolated mechanicalFIGURE 4-20Analysis of an isolated left superior
paretic muscle using the three-step method. In step 1 (a), assuming a rectus (LSR) paresis using oval-like demarcations. (LIO = left inferior
right-eye hyper deviation (RE hyper) n the primary position of gaze, the oblique; LIR = left inferior rectus; LSO = left superior oblique; RE
paretic muscle would be one of four possibilities, including the right hyper = right-eye hyper deviation; RIO = right inferior oblique; RIR =
inferior rectus (RIR), right superior oblique (RSO), left inferior oblique right inferior rectus; RSO = right superior oblique; RSR = right superior
(LIO), and left superior rectus (LSR). These four muscles are shown n the rectus.)
horizontal oval-like demarcations in step 1. In step 2 (b), assuming an
increased right hyper deviation (hyper) in left gaze, the possibilities are problems do not always provide a clear-cut diagno-
reduced to two: RSO and LSR muscles. This is shown by the two oval- sis, as in cases of newly acquired paresis. Further-
like demarcations intersecting with the previously drawn horizontal more, if more than one cyclovertical muscle is
demarcations, the RSO and LSR muscles being common to both hori- involved, the three-step method will not be valid.
zontal and vertical demarcations. In step 3 (c), assuming a further
increase of right hyper deviation on right head tilt, the corresponding Recording Noncomitant Deviations
tilted, oval-like demarcation shows an intersection with the horizontal Jampolsky14 recommended a direct and efficient
and vertical demarcations in which the RSO is common to all three. system of evaluating and recording the motoric
Henee, the diagnosis s RSO paresis. (LIR = left inferior rectus; LSO = left aspects of a strabismus. The objective testing and
superior oblique; RIO = right inferior oblique; RSR = left superior recording procedure can be divided into four
rectus.)as spread of comtancy), the three-step method pars. The evaluation is done with the patient wear-
may give nebulous results. Therefore, this method is ing the habitual refractive correction to ascertain
most useful when there is a newly acquired paresis
of a cyclovertical muscle, whereas it may not be
Chapter4 119

Primarv Position: LE Hyper Primary Position: LE Hyper


c
RIO")
RSR LIO LSR RSR RlOj) LIO LSR
RIR RSO

LSO RSO LSO LIR^)


RIR

Hyper increases on right qaze Hyper increases on right gaze

RSR RICM LSR RIO) LSR


LIO LIO

RIR RSO LSO LIR RIR RSO LSO LIR

Hyper Increases on Left Tilt Hyper Increases on Right Tilt

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

2 eso 5 eso 20 eso


Seso 15 eso 35 eso

2 eso Seso 20 eso


Seso 15 eso 35 eso

2 eso 5 eso 20 eso Seso 15 eso 35 eso

FIGURE 4-23Recordings in a case of left lateral rectus paresis (examiner's view).

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

Grading of Restriction ofLLR

-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

Patient wearing green and red


glasses (provided) is given hand
projector and directed to place
FIGURE 4-26Procedure for Hess-Lancaster testing. green dot inside red circle.
Relationship of dot to circle
The patient s nstructed to place the projected green
makes diagnosis possible.
spot (seen by the left eye) on the projected red spot
(seen by the right eye).

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

Left Field Right Field

El f\

fe*
FIGURE 4-29Chart of the results of
the Hess-Lancaster test in the case of
a paretic right lateral rectus muscle.
(IO = inferior oblique; IR = inferior
rectus; LR = lateral rectus; MR =
medial rectus; SO = superior oblique;
SR = superior rectus.)

exchanges flashlights with the patient. The 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

Left Field Right Field

r.l

FIGURE 4-30Chart of the results in


the case of a paretic right medial rec-
tus muscle. (IO = inferior oblique; IR
= inferior rectus; LR = lateral rectus;
MR = medial rectus; SO = superior
oblique; SR = superior rectus.)
126 Chapter4

LEFT FIELD RIGHT FIELD

FIGURE 4-31 Chart of the results of


paresis of both the right lateral rectus
and the right superior oblique. (IO =
inferior oblique; IR = inferior rectus;
LR = lateral rectus; MR = medial rec-
tus; SO = superior oblique; SR =
superior rectus.)

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

periodic ntermittent strabismus may be either


direct or indirect. Direct means that the strabis- TABLE 4-11. Classifcaton of Frequency of
mus occurs regularly only at near, under specified the Deviation
conditions. Typically, this s the patient with inter-
mittent esotropa at near caused by the combina- Percentaje of
tion of esophoria at far, uncorrected hyperopic Time Deviation
refractive error, and a high AC/A ratio. Accommo- Is Manifest
Type of Strabismus
dation brought nto play for nearpoint demands 100
can preciptate a manifest deviaton. Constant strabismus tnternnttent
1-99
An intermttent strabismus that is periodc and strabismus Periodic
ndirect occurs only at far. Ths s typified by the Direct {strabismus at near)
patent who has ntermittent exotropia at far but ndirect (strabsmus atfar)
who s exophoric at near. Such a patent usually Certain cases of noncomi-
has a hgh AC/A ratio that allows the deviation to
be less at near. At far, however, the individual may Nonperiodk {unpredktabte
intermttence)
regularly lapse into an exotropia unless there is
Nonstrabismus
strong compensational fusional ability.
Another cause for periodcity may be noncom- Heterophoria (deviation
always latent under normaf
tancy. For example, a patent with complete pare-
seelng conditions)
sis of the right lateral rectus muscle has a marked
Orthophoria
noncomitancy, which would likely result in the
patent always havng esotropa in right gaze.
In the majorty of cases, however, the ntermit-
tent regularity of strabismus s uncertain and can- Testng
not be absolutely predicted. Henee, most cases of Estimaton of the frequency of strabismus s not made
intermttent strabismus are nonperiodic. by a rigd system of testing. Rather, t is done by using
professional judgment based on mpressons from the
patient history and results of various testing proce-
Evaluation
dures. Some gudelmes for testing are given here.
There are two principal ways to evalate the per- It s better to observe the patient before rather
centage of time that there s a manifest deviation of than after dissocative testng is begun. The eyes
the visual axes: patient history and results of testng are not dissociated when making direct observa-
procedures. tion, either with or wthout the Hirschberg test.
The cover test, however, fully dissociates the
Patient History eyes. When the cover s removed, any refuson
Patient history information can come from reports movements should be noted and evaluated. A slow
of how others see the patient. Parents of young chil- rather than a quick recovery indcales that the fre-
dren may report that a chld s "cross-eyed about quency of strabismus s relatively high.
half the time, especially when he is tired" or "wall- Diplopia testing reveis the patient's ability to
eyed when he looks out the window or daydream- notice pathologc diplopia. If this condition s eas-
ng." This information s important, because young ly notced when the patient becomes strabismic,
patents seldom report experiencing dplopa. the frequency of strabsmus s relatvely low. In
Older children and adults may gven an ndex contrast, if dplopia seldom is perceived when the
to the frequency of strabismus by reporting the deviation s manfest, the frequency s relatvely
amount of time that diplopia is noticed. This, hgh. Ths s because compensatory fusional ver-
however, s not always hghly correlated wth the gence tends to be better when suppresson s less.
frequency of strabismus, because the individual In other words, diplopa s not likely to be noticed
may use the antdiplopia mechanisms of suppres- in most cases of constant strabsmus (because of
son and ARC. Questionng of the patient's self- suppresson and ARC).
perceived appearance of the eyes and that Many other sensory and motor fusin tests (see
observed by family and frends must, therefore, Chapters 2, 5, and 6) can contribute to the overall
be pursued.
128 Chapter 4

TABLE 4-12. Classification of Direction of TABLE 4-13. Examples of Testing Procedures


Deviation to Determine the Direction of Deviation of the
Visual Axes

Direction of Deviating Eye When


Deviation Fixating Eye Is in Primary Position
Objective procedures
Horizontal Direct observation
Eso Inward rotation of eye Hirschberg test
Exo Outward rotation of eye Krimsky test
Vertical Unilateral cover test
Hyper Upward rotation of eye Altrnate cover test
Hypo Downward rotation of eye Subjective procedures
Torsional von Graefe (vertical prism dissociation)
Incyclo Inward rotation of top of eye
Colored filters
Excyclo Outward rotation of top of eye
Maddox rod
Ph phenomenon

estimation of frequency of a manifest deviation.


This estimation should be determined for far and
near fixation distances. ful if the strabismus is large enough to be
noticeable. If, however, the manifest deviation s
DIRECTION OF THE DEVIATION either small or latent, the cover test is necessary for
diagnostic purposes. Unilateral occlusion is good
The direction of a deviating eye may be horizontal,
for detecting the direction of deviation for lateral
vertical, or torsional, or a combination of these. Table
and vertical components. It has limitations, how-
4-12 lists the directions in which an eye may deviate.
ever, for determining cyclo deviations. (Subjective
methods are more sensitive.)
Classification For example, in the case of a right exotropia
Horizontal deviations n the majority of cases are combined with right hypertropia and right excyclo-
isolated, without a vertical or torsional compo- tropia, covering the left eye would result in the fol-
nent, when al I strabismus and phoria cases are lowing movements: The right eye would be seen to
considered. In contrast, vertical deviations are dif- move inward and downward, with the top of the
ferent n that they often have a horizontal compo- eye (the 12-o'clock position on the limbus) moving
nent (e.g., esotropa with hypertropia). Torsional inward. This is the required movement that the right
deviations (cyclo deviations) almost always have
eye must make to go from the deviated position to
both vertical and horizontal components.
the position of fixation. Unilaterally covering the
Some clinicians speak only of hyper deviations,
strabismic right eye would result in no movement.
thus avoiding use of hypo deviations. We believe
If, however, there s an exophoria combined with a
that this is misleading. For example, it s preferable
right hyperphoria and an excyclophoria, occlusion
to cali a constant unilateral downward deviation of
of the right eye would cause the anterior segment
a nonfixating right eye a right hypotropia rather
of the right eye to drift outwardly and upwardly,
than a left hypertropia. In this case, the left eye s
and the top of the eye would rotate outwardly.
the fixating eye and is not deviating upward, which
The altrnate cover test s another good method
invalidates the diagnosis of left hypertropia.
for determining the direction of the deviation.
Testing procedures to determine the direction of
Neutralizing prisms will provide the desired nfor-
deviation may be either objective or subjective
mation. When the lateral (horizontal) component
(Table 4-13).
is neutralized, either with BO or Bl (base -in)
Objective Testing prism, the vertical component is much easier to
observe. If the vertical component also is neutral-
When there s a manifest deviation, direct observa-
ized with either BU (base-up) or BD prism, t may
tion, the Hirschberg test, or the Krimsky test s use-
be possible to isolate and observe cyclo deviations
Chapter 4 129

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

FIGURE 4-32Explanation of cyclo


deviation testing using Maddox rods.
a. The patient perceives the maged
Une as being vertically oriented for the
fixating left eye. However, the line a. O.S. VISUAL PERCEPTION O.D. VISUAL PERCEPTION (POINTS X
seen by the right eye appears to be AND Y ARE NOT SEEN, BUT ARE ONLY
FOR EXPLANATION PURPOSES)
slanting, with the top oriented in a left-
ward position. b. Posterior view of the
eyeballs, illustrating the excyclo devia-
tion of the right eye. The analogy of
b. IMAGE OF MADDOX ROD
visual fields and retinal projection is
used here for clarification. Point x VERTCAL MERIDIAN OF RETINA
stimulates the superior nasal retina and OF EXCYCLOTROPIC RIGHT EYE
is therefore projected into the inferior
temporal field. Likewise, point yon the
inferior temporal retina is projected
into the superior nasal field. c. The
slanted line seen by the right eye s O.S. O.D.
seen to the left of the vertical line
because of a horizontal exo deviation POSTERIOR VIEW OF RETINAS
of the right eye. d. Many practitioners
prefer to place the axis of the rods at
90 degrees so the patient sees horizon-
tal streaks (n this example, by the left
eye). If a vertical prism is placed base-
down before the right eye, the excyclo
deviation causes the perceived streak
for the right eye to slant upward in the
temporal field and downward in the O.D.
nasal visual field. The vertical prism s
necessary to crate the doubling so
that one line s above the other. This
may be unnecessary f the patient has O.S.

an existing vertical deviation. (O.D. =


O.D.
oculus dexter; O.S. = oculus sinister.)
d, PATIENT'S PERCEPTION
C. PATIENTS PERCEPTION

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

TABLE 4-14. Classification of Magnitude of TABLE 4-15. Classification of Magnitude of


Strabismic Deviation on Basis of Cosmesis Strabismic Deviation on Basis of Prognosis for
Functional Cure (with Prsm Compensation and/or
Training Techniques)
Cosmetic Esotropa Hypertropia
Effect and
A
Exotropia ( ) Esotropa Ixotropia Hypertropia
A A
Small (usually 1-10 Magnitude W () ()
acceptable) 1-15 1-10 1-15 1-5
Modrate 11-20 11-20 16-25 6-10
(somet mes 16-30 >20 >25
unacceptable) Small
Large (usually 20 Modrate
unacceptable) >30 Large

in accord with our recommendations. Classification


of strabismus magnitude based on cosmetic accept-
Classification ability is given n Table 4-14. Horizontal Strabismic
A
deviations greater than 20 and vertical Strabismic
Classification of the magnitude of heterophoric A
deviations greater than 15 are often unacceptable
deviations s somewhat nebulous in that the devia-
cosmetically.
tion is latent and, thus, not cosmetically noticeable.
Another aspect of magnitude Classification is the
Although cosmesis s not of concern, binocular
functional cure approach (Table 4-15). This classifi-
function may sometimes be related to magnitude. In
cation determinan! involves the predicted outcome
general, a very large deviation tends to cause symp-
f nonsurgical means (i.e., prism compensation,
toms and may affect performance in school, work,
visin training techniques, or both) are used to
and play. There are many exceptions, however. For A
cure the strabismus. An esotropa greater than 20
example, a small esophoria may play havoc with an
may require surgical reduction, because excessive
individuaos comfort and performance when read-
prismatic power s needed to compnsate for the
ing, f fusional divergence is nadequate and there is
deviation. Comfort and cosmetic acceptance may
an eso fixation disparity. On the other hand, we
be problems, as may limitations of fusional diver-
have seen patients with relatively large esophoria
gence training, which often does not produce the
who are comfortable and perform well at school,
desired result n large Strabismic deviations. A
work, or play, possibly because of excellent fusional
greater magnitude is allowed in exotropia because
divergence and the absence of fixation disparity.
fusional convergence is more robust than s fusional
The factors discussed in Chapter 2 relating to visual
divergence in most cases, and t can usually be
skills efficiency must be taken into account when
ncreased sufficiently with functional training tech-
correlating magnitude of heterophoria with comfort
niques. However, patients with an exo deviation
and performance. Nevertheless, the magnitude A
greater than 25 should be considered as possible
classifications that follow for strabismus may also
candidates for surgery. Vertical deviations cannot
be useful as guidelines n heterophoria.
be mproved greatly with training in most cases,
The question of what constitutes small and large
and they may require prismatic compensation.
strabismus needs answering. The Classification of A
16 Hypertropia greater than 10 is, therefore, consid-
von Noorden (as cited by Press ) states that an
ered large. These are only general guidelines for a
acceptable surgical result n nfantile strabismus s
A functional description; there are many exceptions
less than 20 , which s classified as small; an unac-
A n clinical practice.
ceptable result exceeds 20 , which s classified as
large-angle strabismus. This Classification is based
mainly on cosmetic evaluation, and we concur with Testing Procedures
A
the determination that a 20 finding should be con- Testing for magnitude can be undertaken with the
sidered large, as the deviation s usually noticeable procedures listed n Table 4-13, which determine
and may be a cosmetic problem. This is somewhat the direction of a deviation of the visual axes.
132 Chapter 4

on convergence (with the altrnate cover test). At


TABLE4-T6. Classificaton of Alternation of the farpoint, minus lenses are used for this pur-
Strabismus at Far and Near pose. At the nearpoint, either plus or minus lenses
will give the valu. Regardless of the testing dis-
tance, the AC/A ratio should be determined with
Unilateral Strabismic rght eye
the patient wearing full-plus farpoint refractive
Strabismlc left eye
correction (i.e., corrected ametropia most plus
Aftemating Habitual afternation
[CAMP] lenses) (see Chapter 2).
Rlght eye preferred for fixation Left
The following s an example of the gradient
eye preferred for f ixatiorv Forced
method. Assume that the patient has an exotropia of
alternation
15A at far. A spherical lens of -2.50 D is placed
before each eye in free space, and the patient is
instructed to focus and clear the fixation target while
looking through the lenses. When the target is
Although the magnitude may be measured by sub- reported to be clear, another measurement of the
jective and objective methods, there are times angle of deviation is made (e.g., altrnate cover test).
when measurement by subjective means s prefera- If the lenses cause the angle to change from 15A exo
ble. This is because objective testing may lack nec- to ortho, the AC/A ratio is 6 to 1, determined by
essary precisin, as in cyclo deviation. Subjective dividing the change in magnitude of the deviation by
testing, however, is not always reliable, especially the change of accommodative stimulus.
when there is deep suppression or ARC or the
patient is a poor observer.
Subjective methods designed for the determi- EYE LATERALITY
nation of the magnitude of deviation are varia- In cases of strabismus, eye laterality refers to whether
tions of either the single-object or the two-object only one eye or either eye is able to maintain fixa-
method. The measuring tools are either prisms or tion. This determination should be made at far and
calibrated scales. The scales may be in true space. near fixation distances. If only one eye is able to fix-
For example, in the Hess-Lancaster test, the ate, the strabismus is classified as unilateral, whereas
patient directly views the test targets, and their f either eye can fixate, t is an alternating strabismus
separation can be converted into prism diopters (Table 4-16). Alternation should be classified as
by using the measurement lines on the screen. In either habitual or forced. Habitual alternation means
contrast, when haploscopes such as the major the patient switches fixation naturally, without being
amblyoscope (discussed in subsequent chapters) aware of doing so. In forced alternation, the patient
are used, the deviation is measured from scales must made be aware of the need or instructed to
on the instrument. altrnate. The degree of forcing indicates the patient's
tendency to altrnate or not altrnate. This important
information should be included in the evaluation of
ACCOMMODAT1VE-CONVERGENCE/
eye laterality.
ACCOMMODATION RATIO Evaluation is made by such means as the Hir-
The AC/A ratio means that for every diopter of schberg test, unilateral cover test, patient history,
accommodative response, a certain amount of and direct observation of the patient. judgment is
accommodative convergence is brought into play, made regarding whether a patient fixates with
depending on the valu of the ratio. For example, if either eye (and the frequency of fixation with each)
the AC/A is 6A per 1.00 D of accommodative or whether fixation is confined to one eye. An
response, a patient who accommodates 2.50 D interesting characteristic of many strabismics is
will have an increased convergence of 15A. In stra- alternation of fixation on lateral versions. The cli-
bismus cases, the ca/cu/afecfAC/A is determined in nician can observe whether a patient switches fix-
the same manner as was described in Chapter 3. ation at the midline with lateral pursuits to the
However, a gradient AC/A in strabismic patients right and left. For example, in left gaze, an esotro-
usually is not defined using phoropter measure- pic patient may prefer the right eye for fixation,
ments, although it may be determined by finding whereas in right gaze, the left eye may be pre-
the effect of spherical lenses (from a trial lens set) ferred. The presence of such a midline switch
Chapter 4 133

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

TABLE 4-17. Anatomic Factors in REFERENCES


Strabismc Cosmesis 1. Fisher NF. General principies of esotropa. Audio Digest
Ophthalmol. 1972;10(18):sde B.
2. Hirschberg J. ber die Messung des Schielgrades und
Favorable for Favorable for Dosierung der Schieloperation. Centralbl Prakt Augen-
Esotropa, Exotropia, keilkd. 1885;9:325-327.
Unfavorable for Unfavorable for 3. Jones R, Eskridge JB. The Hirschberg test: a re-evaluation.
Exotropia Esotropa Am ] Optom Arch Am Acad Optom. 1970;47:105-114.
4. Griff'm JR, Boyer F. Strabismus: measurement with the
Positive angle kappa Negative angle kappa Hirschberg test. Optom Wkly. 1974;75:863-866.
5. Riddell PM, Heinline L, Abramov I. Calibration of the
Narrow brdge of rvos0 Wide bridf e of nose
Hirschberg test in human infants. Invest Ophthalmol Vis
Absent of epicanthus Presence of epicanthus Sc. 1994)35:538-543.
Large interpupillary dis- Small interpupillary dis- 6. Hasebe S, Ohtsuki H, Kono R, NakahiraY. Biometric con-
tance Narrow face tance Wide face firmation of the Hirschberg ratio in Strabismus children.
Invest Ophthalmol Vis Sci. 1998;39:2782-2785.
7. Eskridge JB. The complete cover test. ) Am Optom Assoc.
1973;44:601-609.
8. Choi RY, Kishner BJ. The accuracy of experienced strabis-
A mologists using the Hirschberg and Krimsky tests. Oph-
ing an esotropa of 20 . However, surgery for cos-
thalmology. 1998;105:1301-1306.
metic reasons alone may not be necessary for such 9. Hasebe S, Ohtsuki H, Tadokoro Y, et al. The reability of a
a patient if he or she has a large positive angle video-enhanced Hirschberg test under clinical condi-
kappa, a narrow bridge, no epicanthal folds, a tions. Invest Ophthalmol Vis Sci. 1995;36:2678-2685.
large interpupillary distance, and a narrow face. 10. Griffin JR, Cotter S. The Brckner test: evaluation of clinical
Under these conditions, the eyes are likely to usefulness. AmJ Optom Physiol Opt. 1986;63:957-961.
11. Griffin JR, McLin L, Schor CM. Photographic method for
appear cosmetically straight. It s possible that the Brckner and Hirschberg testing. Optom Vis Sci. 1989;66:
eyes would appear exotropic if the eso deviation 474^479.
were significantly reduced by means of surgery. 12. Parks MM. Isolated cyclovertical muscle palsy. Arch Oph
Consequently, it is always wise to observe the thalmol. 1958;60:1027-1035.
patient carefully and weigh the various factors 13. Bajandas FJ, Kline LB. Neuro-Ophthalmology Review
Manual. Thorofare, NJ: Slack Inc.; 1987:103.
influencing appearance before reaching any con- 14. Jampolsky A. A Simplified Approach to Strabismus Diag
clusin regarding extraocular muscle surgery. nosis. In: Symptoms on Strabismus, Transaction of the
The effect of eyewear on cosmesis should also be New Orleans Academy of Ophthalmology. St. Louis: C.V.
taken into account. A certain spectacle frame may Mosby; 1971:34-92.
either help or hinder the strabismic individual's 15. Howarth PA, Herm G. Repeated measures of horizontal
heterophoria. Optom Vis Sci. 2000;77:616-619.
appearance. Trial of different sizes and patterns and
16. Press LJ. Topical review: Strabismus. J Optom Vision Dev.
keen observation of the patient's appearance are the 1991;22:5-20.
rules to follow.
chapter 5 / Sensory Adaptations to Strabismus

Suppression 135 Haidinger Brush Testing 161


Cnaraetenstics of Suppression 136 Refraction Procedures 163 Eye
Testing for Suppression 139 Disease Evaluation 163
History 140 Red Lens Test Ophthalmoscopy 163
140 WorthDotTest 140 Visual Felds 164
Ambiyoscope Workup 141 Neutral-Density Filters 164
Amblyopia 143 Tests of Retinal Function 165
Classification 144 Strabismic Screening for Amblyopia 165
Amblyopia 144 Anisometropic Anomalous Corresponderse 166
Amblyopia 144 Isoametropic Classification 167 Characteristics
Amblyopia 145 Image Degradation 170
Amblyopia 145 Horopter in Anomalous Retinal
Amblyopia as a Correspondence 170
Developmental Disorder 145 Horror Fusionis 172
Case History 148 Etiology of Anomalous Retinal
Visual Acuity Testing 149 Snellen Correspondence 174
Charts 149 Bailey-Lovie Chart 151 Depth of Anomalous Retinal
Psychometric Charts 151 Tumbling E Correspondence 175
and Pieture Cards 153 Infant Visual Prevalence of Anomalous Retinal
Acuity Assessment 154 Visually Correspondence 176
Evoked Potentials 158 Testing 176
Interferometiy 159 Dissociated Red Lens Test 176
Fixation Evaluation 159 Description o Afterimages 176
Eccentric Fixation 160 Vsuoscopy Bifoveal Test of Cppers 179
160 Major Ambiyoscope 182
Bagolini Striated Lenses 183
Color Fusin 185

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

FIGURE 5-1Confusin and diplopia n an example of


esotropa of the right eye and the resulting pathologic
suppression. a. Cyclopean perception of confusin and
pathologic homonymous diplopia. The fixation starlike
object s seen diplopically. The nonfixated circle falling
on the fovea of the deviating right eye causes confu-
sin. Although the circle could possibly be seen
o.s.
diplopically, it is not usually noticed, as the patient is
not paying it any attention. b. Theoretical posterior
view of the eyes showing the suppression zone that
could result from the esotropic right eye. c. Theoretical
ophthalmoscopic view of the right fundus, illustrating
the shape and location of the suppression zone. (f =
fovea; H = horizontal angle of deviation; O.D. = oculus
dexter; O.S. = oculus sinister.)

c. O.O. FUNDUS

that is usually attempted first by an individual to can quickly develop n the


elimnate these perceptual annoyances. Suppression turned eye if the child fails to develop an altrnate
s the lack of perception of normally visible objects in fixation pattern. Stereoacuity, however, can continu
all or part of the field of visin of one eye, occurring to develop in the presence of a constant strabismus,
only under binocular viewing conditions and although not to the same degree as when the eyes are
attributed to cortical inhibition. 1 In normal binocular straight. In the case of anisometropia, suppression is
visin, physiologic suppression naturally occurs, directly related to the degree of the refractive
particularly, foralJ objects fallingoutsjdethe singleness difference between the eyes, and the development of
horopter. The suppressed rnageecn usually be brought stereopsis s affected accordingly. 7 Early identification
to consciousness by directing attention to it. On the of disorders of binocular visin that cause
other hand, pathologic suppression s a binocular suppression and result n amblyopia and reduced
anomaly. In the presence of strabis-mus, for example, a Stereoacuity s a desirable public health goal, as t
suppressed image s not easily \perceived by merely makes the successful management of such
directing one's attention to it. mere is, apparently, conditions much easier.In cases of excessive
active cortical inhibition of the suppressed eye's mage heterophoria and intermit-tent strabismus
that s not as subject to voli-tional control, von Noorden 2 (particularly intermittent exotro-pia), testing for
noted that even retinal rivalry disappears in strabismic suppression usually requires very sensitive
patients. Retinal rivalry (see Chapter 1) and suppression controls, such as the altrnate polarized
suppression both occur in the visual cortex, although letter test found on the Vectographic Slide (see Figure
they may be mediated by other neural processes.3 3-10) and the Mentor B-VAT Binocular Vision Testing
Suppression that occurs during infancy and early System.8Characteristics of SuppressionThe precise
childhood can have a profound effect on the devel- neurologic mechanism for suppression is not
opment of the full acuity potential of the affected eye thoroughly known, but the phenomenon can be easily
and maturation of stereopsis. When the images of each demonstrated by diagram. Figure 5-1 illus-trates the
eye are discordant due to strabismus or uncorrected concept of diplopia and confusin and the resulting
anisometropia, there s active cortical inhibition n zone of suppression. The fixation target s imaged on
V1 related to the affected eye that slows or halts the fixating left eye. An esotropa of the right eye
further sensory development.4 Stereopsis (binocular causes the target's mage to fall on the nasal retina.
depth disparity detection) starts to develop n normal Cyclopean projection shows the patient per-ceiving
infants at approximately 2.5-4.0 months of age and two images. When the diplopic mage s seen on the
progresses rapidly.5 The onset of strabismus at this same side as the eye that deviates (e.g., right eye
early time has the most disruptive effect. 6 Amblyopia seeing the diplopic mage in the right field),
Chapter 5 137

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

FIGURE 5-2Horizontal visual field limits.


a. Orthophoria. b. Esotropa of the left eye.
c. Exotropia of the left eye. (f = fovea.)

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

sion will be found. If anomalous retinal correspon-


TABLE 5-1. Size of Suppression Zone in Either dence (ARC) s present, these relations do not
Supermposition or Fused Targets necessarily apply, because ARC s also an antidi-
plopia mechanism that partially obviates the need
for suppression.
Separation from Target Center Suppression is usually shallow in noncomitant
QassJficatlon to Suppression Clue strabismic patients. Intensity is less because the
Central Foveal <5 degrees <1 degree <3 magnitude of the deviation is continuously chang-
Parafoveal degrees (but >1 degree} <5 ing as fixation shifts from one field of gaze to
Paramacular degrees (but >1 degree} >5 another. This means that point zero (the target
Peripheral degrees point) is not at a fixed site on the retina; thus,
diplopia is more likely to be perceived. Fortu-
nately, the accompanying diplopia with noncomi-
nated room has shallow suppression. In contrast, if tant deviations can warn individuis of possible
the room must be darkened and the patient must neurologic problems that require immediate health
wear red-green filters to perceive diplopia, then care attention.
the suppression would be deep.
Several attributes of the strabismic deviation
affect the suppression response. Magnitude of the Testing for Suppression
deviation is one: Generally, the larger the devia- The number of tests for suppression s legin. Only
tion, the larger is the suppression zone. The inten- some of the basic methods are presented here for
sity of suppression, however, s not necessarily assessing suppression associated with strabismus. All
correlated with the magnitude. It may be that a of these, except the major amblyoscope, are readily
patient with a constant, small-angle esotropa will available to the primary eye care practitioner. The
have a small suppression zone but one that s sup- patient should be wearing appropriate optical cor-
pressed very deeply. Another factor s eye laterality. rection (corrected ametropia with most plus [CAMP]
If the strabismus s alternating, the suppression is lenses for best visual acuity) if needed. For screening
also likely to altrnate from eye to eye. If the stra- purposes, a simple test for suppression can be used
bismus is unilateral, suppression is confined to the effectively for 5-year-old children.11 We recommend
deviating eye. Frequency of the strabismus is the Pola-Mirror test (.e., crossed-polarizing filters
another important variable. The more frequent the and a mirror) as a simple, easy, nexpensive, and
strabismus, the more likely is it that deep suppres- sensitive screening test for suppression associated

TABLE 5-2. Tests for Intensity of Suppression

Naturalness of Intensity of
Testing Method of Testing Instrumentation Suppression

Natural Diplopia n free spaee Ordinaryobjects Shatlow


Penlight
Vectographic methods Pota-Mlrror
Vis--vs (Griff in) test
Vectograms
Septums Torvlle test
Bar reading
Septums with optical systems Brewster stereoscope
Wheatstone stereoscope
Coiored filters Red lens test
Unnatural Worth four-dot test Deep
140 Chapter 5

one pink light (a fusin response), or both a red and


a white light (indicating diplopia). Strabismic indi-
viduis having harmonious ARC may report seeing
some variation of a pink light, simulating a normal
fusin response. Patients who suppress and have
alternating strabismus will report seeing the light
change from red to white. If only one red light s
seen, the depth of suppression can be assessed by
sequentially adding neutral-density (gray) lenses to
the dominant eye until diplopia can be noticed.
Creen Filter Red Fllter
When mltiple filters are necessary to elicit diplo-
pia, deep suppression is indicated. Another method
for assessing the ntensity of suppression s to dim
the room light until diplopia of the penlight image
is noticed. If no diplopia is seen in a dark room, the
suppression can be considered to be deep.

Worth Dot Test


The Worth dot (four-dot) test is similar to the red
lens test, but t s more popular. Red-green filters
FIGURE 5-3Worth four-dot test n a case of esotropa of the left eye.
(f = fovea; C = green; R = red; W = white.)
are worn by the patient over any needed specta-
cles. By convention, the red filter s placed before
the right eye and the green before the left. The test
with amblyopia, strabismus, and uncorrected ani-
s administered under two lighting conditions, full
sometropia. The vis--vis test, introduced by Griffin,
room illumination and dark. A Worth flashlight s
is similar to the Pola-Mirror test except that there s
held with the white dot (of the four dots) oriented
no mirror; rather, the patient and doctor face each
on the top (Figure 5-3). The examiner stands across
other from a distance of approximately 50 cm, with
the room from the patient and asks how many
both wearing crossed-polarizing filters. Suppression
lights are perceived. A report of two red dots indi-
is indicated f one of the doctor's eyes appears dark-
cates suppression of the green-filtered eye. A report of
ened. (Refer to Chapter 12.)
three green dots means suppression of the red-filtered
History eye. A four-dot response suggests second-degree
Strabismic patients should be questioned f they sensory fusin at that testing distance and under
notice diplopia under natural viewing conditions: those particular test conditions. Altrnate suppres-
Are the double images only at a particular distance sion s indicated f the patient reports switching
or n a certain field of gaze? Are the double images between two and three lights. A report of five dots
present at all times or just occasionally? Is diplopia (two red and three green) indicates diplopia. The
noticed only when the patient s thinking about t examiner notes the response at far and then slowly
and ignored at other times? moves toward the patient. The patient reports any
changes n the perception of the dots as the exam-
Red Lens Test iner advances the Worth flashlight to 10 cm from
Por the red lens test, the patient, wearing a red filter the patient. It s customary to record the patient's
over one eye, views a fixation light in a normally responses at least at far (6 m) and at near (40 cm).
lluminated testing room at a distance at which the If the initial test was done with the room lights on,
strabismus s manifest. The patient s asked whether t s repeated with the lights off.
one or two lights are visible. Seeing two lights The interpretation of test results can be com-
under these conditions indicates that the suppres- plex. The Worth dot test at far assesses central sen-
sion is either relatively shallow or s absent. If one sory fusin if the angle subtends the dots at less
light s reported, a red lens or filter should be than 10 degrees. As the flashlight is advanced
nserted before the fixating eye, and the patient toward the patient, peripheral fusin can be
should be asked whether he or she sees one light assessed. Also as the flashlight is moved closer,
that is either red or white (a suppression response), the ntensity of the lights on the retina ncreases,
Chapter 5 141

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).

Automatic Flashing (Models 2051 and 2052 only).

35. Automatic flashing unit.


36. On/Otf switch.
37. Indicator lamp.
38. Rapid/Variable switch.
39. Simultaneous/Alternating switch.
40. Light and darle phases controls (2).
50. Fuse.

Haidinger's brushes (Model 2051 only).

42. On/Off switches.


43. Reversing switches (2).
44. Speed controls (2).
45. Plug and socket connections to motors (2).
46. Motors and rotating polaroid discs (removable from
Instruments) (2).
47. Haidinger's brush illumination switches (21.
48. Blue filters (removable) (2).
49. Iris diaphragms (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

BASE-OUT EXAMPLES OF SUPERIMPOSITION


SLIDES FOR THE SYNOPTOPHORE.

G1 SOLDIER G2 SENTRY BOX

a.

O.S. O.D. BASE-IN G47 FISH G48-TANK

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

amblyopia ncidence of 50% for hyperopic aniso-


metropes of 2 D and of 100% incidence for 3.5 D TABLE 5-3. Common Causes of Image
or greater. Most nvestigators have found a strong Degradation Amblyopia
correlation between the amount of hyperopic aniso-
metropia and severity of amblyopia9'22'23; however, rt
Congenital cataracts
is possible for a patient with only a small amount of
Ptosis
anisometropia and no strabismus to have deep
Corneal opacties
amblyopia.12 Generally speaking, binocular fusin
Other media opacities
becomes weak and stereoacuity decreases in pro-
Occlusion (iatrogenic cause)
portion to the depth of anisometropic amblyopia,
according toTomac and Birdal.24
Myopic anisometropia does not generally result
in deep (or as prevalent) amblyopia as does the that remained uncorrected during early childhood
hyperopic variety. The uncorrected hyperopic (before age 7 years). These patients typically have a
anisometrope typically focuses to the level of the mild mpairment of acuity, 20/30-20/70, n each
least hyperopic eye, leaving the more hyperopic eye when the ametropia s first optically corrected.12
eye permanently deprived of a clear image. The Due to the bilateral nature of this type of amblyopia,
uncorrected myopic anisometrope, on the other t usually is detected earlier than is anisometropic
hand, often alternates fixation, because each eye is amblyopia, because the child cannot see clearly
independently in focus at a different near distance. with either eye. Because the images are equally
Tanlamai and Goss21 reported an amblyopia inci- blurred, there is little or no suppression.26This may
dence of 50% among myopic anisometropes of 5 explain, n part, why the effects of a bilateral loss of
D and of 100% for 6.5 D and greater. If reduced acuity are less severe than with anisometropia and,
unilateral visual acuity s found associated with a consequently, why the condition usually responds
small degree of myopic anisometropia (e.g., oculus well to visin therapy. Fortunately, visual acuity
dexter, -2.00 20/60; oculus sinister, plano 20/20) often improves spontaneously after spectacles or
and strabismus is absent, then the clinician should contact lenses are worn for a few weeks or months.
suspect an organic or other cause of reduced acu- Vision training sometimes proves useful too and,
ity until proven otherwise. frequently, normal or nearly normal visual acuities
Generally, anisometropic amblyopia s not are achieved.
highly associated with EF, although there are many
exceptions. In most cases, the fixation s central Image Degradaton Amblyopia
but unsteady. There appears to be increased spatial
Reduced visual acuity caused by a physical obstruc-
uncertainty regarding visual direction, but the
tion to clear visin during early childhood that
time-averaged position of fixation usual ly s not
results n severe light and form stimulus deprivation
shifted away from the fovea.
s sometimes called image degradation amblyopia.
Uncorrected astigmatic anisometropia of 1.50-D
The most common causes of this type of amblyopia
cylinder or greater early n Ufe can also result in
are congenital cataracts that are removed much
amblyopia for sharp contours in the deprived merid-
later in Ufe (Table 5-3). Because of abnormal binoc-
ional orientation. Meridional amblyopia is usually
ular interactions, unilateral light or form deprivation
not severe. Patients frequently show significant
results n deeper amblyopia than would binocular
improvement after a few weeks or months of wear-
deprivation for the same period.27 Stimulus depriva-
ing the appropriate spectacle or contact lens correc-
tion of one or both eyes before age 1 year can lead
tion. Part-time occlusion of the dominant eye also
to profound and permanent visual acuity loss as
promotes rapid progress n these cases, unless the
well as nystagmus. Early and effective treatment s
ametropia s of long duration since early childhood.
absolutely critical for remediation of acuity.
Isoametropic Amblyopia
Isoametropic amblyopia s relatively rare. Agatston25 Amblyopia as a
reported this condition n approximately 0.03% of Developmental Disorder
Army draftees. It is secondary to high symmetric Amblyopia may be considered to be a developmen-
refractive error (hyperopia, myopia, or astigmatism) tal disorder of spatial visin caused by some type of
146 Chapter 5

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

FIGURE 5-8Example of Snellen chart


designs in which there s neither an ade-
quate number of larger letters as com-
pared with smaller letters or control for
interletter spacing.
150 Chapter 5

E DNUP
LO e T E V B C L

T L V Z FIGURE 5-10Larger Snellen letters having smaller spacing to cause


greater crowding effect than the smaller Snellen letters.

(E)
Using Landolt Cs and movable interacting bars,

A T P E D Flom et al.44 found that contour interaction started


to affect resolution of the gap n the C when the bar
spacing equaled the distance of one letter. Mxi-
(T) (B)
mum effect occurred when the spacings of the bars
were 40% of a letter size. Flom et al.,44 however,
P E C F L challenged the conventional wisdom that ambly-
opic eyes are more affected by contour interaction.
(B) (P) They maintained that the effect is approximately
equal at threshold visual acuity levis for both nor-

E D F C Z P mal and amblyopic eyes.


The letter spacing vares on each line on the
(B) (P) (E) Snellen chart and so does the crowding phenome-
non. On the 20/20 (6/6) line of a typical Snellen
A L O P Z D chart sude, the spacing is large, well beyond the
(S) (G) (E) (B) (P) distance causing contour interaction. However, the
spaces between letters in some Snellen charts are
relatively reduced for larger letters in the threshold
FIGURE 5-9Typical responses during testing of an amblyopic eye. acuity range of many amblyopes. These patients
Patient's ncorrect calis are shown parenthetically.
would show significant contour interaction effect,
whereas a person having 20/20 acuity would not.
patient, for example, will consistently identify (See Figure 5-10 for clarification.)
smaller and smaller letters up to a certain point. It is commonly observed that amblyopic visual
Beyond that, letters are consistently missed if an
attempt is made to guess the appropriate letters. In acuity is better for isolated letters or, possibly, for a
contrast to this response, the patient reading with an single line of letters than for full Snellen chart acuity.
amblyopic eye will show wide variation in correctly These differences in acuities were reported by
identifying different-sized letters (Figure 5-9). The
typical response is to read one or two letters cor- Morad et al.45 This phenomenon is usually explained
rectly in each of several lines with no clear-cut on the basis of the impaired "aiming" ability of an
threshold. The patient often properly recognizes the amblyopic eye rather than on the basis of contour
first and last letters of any particular line, whereas
the ones in between are not correctly recognized. interaction. In a complex detailed visual field,
One reason often given for such differences amblyopic spatial uncertainty and unsteady fixation
between amblyopic and nonamblyopic test result in an increased number of fixation errors. A
responses is the effect of contour interaction, some- restricted field with fewer letters is less confusing to
times referred to as the crowding phenomenon, in an amblyopic observer; therefore, each letter can be
which neighboring contours impair the resolution of fixated more easily.
the fixated letter. Contour interaction reportedly When testing with the Snellen chart, the clini-
affects amblyopic eyes more than normal eyes. cian should suspect amblyopia if (1) letters are
missed on several lines using the full chart, (2) let-
Chapter 5 151

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

ame (OD) (OS) OU Dat e


city 1 degree nasal O.D. (v/ Rx)
Eccentri
Mosl of llfe, right eye amblyopia w/o Rx
Duration
1
4- -H- ........ Lefteye,-
9 1 5 2 0 26 32 L D R D U D R U lio
4-
- SS^
2
3

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

X RU LR RL U pX RRL " DL X Ufl

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].)

Tumbling E and Picture Cards


Hand-held tumbling E cards are a popular acuity
test for use with young children or older patients
who are illiterate or for those who do not know the
Romn alphabet (e.g., in the English language).
Two sets of cards are available (see Suppliers and
Equipment n Appendix J), one with contour inter-
action bars and one without such bars (Figure 5-
15). The acuity levis range from 20/20 to 20/200
n eight steps. Visual acuity threshold is estab-
lished by finding the threshold distance for a letter
of particular size. For example, the examiner can
start testing a child at 3 ft with a 10-ft letter. The
patient is to indcate the correct orientation of the
E, and the criterion for determining the threshold
154 Chapter 5

advantages and limitations. Figure 5-16 shows the

mam cereal test, and Figure 5-17 shows the broken-


wheel test. These visual acuity test targets are
approximately equivalent to Snellen optotype in
EDE angular size and are very appealing to preschool-
aged children. They all are considered to be a rec-

RES ognition acuity task in which the child is asked to


discrimnate a test form from among a small set of
similar shapes known to the child.
The lighthouse symbols (Figure 5-18) are excel-
FIGURE 5-14Psychometric acuity test design of Davidson and lent targets for young children. A sophisticated
Eskridge of the commercially available Wesson charts. group of visual acuity charts for preschool children
is the Lea symbol tests. This series of charts,
designed by Lea Hyvarinen, has some advantages
distance is at the 80% level (i.e., correct responses over other children's charts. The four symbols (ball,
to four of five triis). The examiner would ask the box, house, apple) communicate well to children
patient, "In which direction are the legs of the E (30 months-7 years) and, when indistinct or out of
pointingup, down, left, or right?" A patient's focus, appear to have the same overall shape, that
responses might be verbal or nonverbal; a child of a circle. The symbols on the charts are equally
may be more comfortable pointing with fingers to spaced and arranged in a logMAR progression.
indcate the direction of the tumbling E. If four of Various test layouts are available: single-symbol
five responses are correct, then the examiner (one per page) book, symbol charts from 8 to 14
backs away a few steps and retests at that distance. lines, near-vision card, simulated reading card
This process contines until a distance is found at (crowded, textlike format), and domino cards for
which the patient cannot achieve the 80% correct matching. There are also two low-contrast forms of
criterion. The farthest distance from the patient in the test for contrast sensitivity testing. The far charts
which 80% correct calis were made represents the are calibrated for testing at 10 ft, but actual acuity
visual acuity threshold. If that distance is 7 ft away vales at other test distances can be quickly deter-
from the patient using a 10-ft letter, the acuity is 71 mined using the conversin table provided in the
10, which transales to 20/28.6 or approximately manual. The actual visual acuity (VA) at other test
20/30. (Use the formula 7/10 = 20/x and solve for distances can also be calculated simply by using
x.) the following formula:
Amblyopia is suspected if the patient is fully
VA =
corrected optically and yet shows poorer acuity in
one eye than in the other. In a young child, there is Viewing distance (feet) x VA valu for 10 ft
often a question whether reduced acuity is due to 10ft
psychological variables (e.g., inattention, poor 20
_ _
cooperation, hysteria). The contour interaction For example, 40 _
tumbling Ecards can add further evidence in cases 10 12
of suspected amblyopia. If a child demonstrates The Lea
relatively poor acuity in one eye, the threshold symbol charts have proven their merit in
should be remeasured using the interaction bar E screening for amblyopia in young children;
cards. If that acuity is further reduced significantly however, these charts are reported to yield better
using the bar cards, it suggests that developmental acuity by one Une (e.g., 20/30 versus 20/40) as
amblyopia is present and does not have a psycho- compared with Landolt Cs or Bailey-Lovie letter
logical basis. Contour interaction occurs maxi- charts.45
mally when threshold letters are used.44
Several other sets of available visual acuity test Infant Visual Acuity Assessment
cards are suitable for preschoolers, ages 2-5 years. Amblyopia screening in infants relies primarily on
However, unlike the tumbling Es, they do not have objective methods to identify the specific amblyo-
contour interaction bars to aid in amblyopia identi- genic cause (i.e., usually constant strabismus or
fication. Nonetheless, each has its own particular anisometropia). However, an informal inferential
ChapterB 155
156 ChapterB

FIGURE 5-16Cereal test for visual acuity.


FIGURE 5-17Broken-wheel test for visual acuity.

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.

Visually Evoked Potentials


In nfants n whom amblyopia s indicated by these
direct observations or by preferential looking meth-
ods or other clinical assessments, it may be valuable
to access acuity further by visually evoked potential
(VEP) methods.
The early works by White and Eason49 on evoked
cortical potentials in the occipital lobe have led to
great interest in evaluating visin by electroencepha-
lographic means. By analyzingVEPs displayed graph-
FIGURE 5-20Optokinetic nystagmus (OKN) drum used to detect
ically as a plot of amplitude against time, visual
amblyopia. acuity can be determined. The visually evoked poten-
tial is known also as the visually evoked response
and the visually evoked cortical potential.
One of the most mportant uses of the VEP s
lutions per minute. The examiner evaluates the determining whether a patient has an organic lesin
responses to nasalward and temporalward stimu- resulting in decreased visual acuity. Harding50
lation, respectively, while comparing responses believed that organic causes can be ruled n or out
of the right eye with the left eye. Although there by use of formless flash stimuli. A transient VEP,
are pediatric OKN drums with colored pictures, which is a stroboscopically presented stimulus, will
we have found the standard striped drum to be elicit a graph cal representation of the elctrica!
more effective in assessing OKN asymmetries activity of the visual cortex. This pattern is evaluated
(Figure 5-20). in terms of (1) amplitude, (2) latency of occurrence
of the major positive peak response, and (3) general
LATENCY
waveform morphology. A computerized recording
showing a reduced amplitude indicates a lesin
FIGURE 5-21Transient visually evoked potentials graph showing somewhere in the visual pathways. Amplitude
reduction may indcate optic atrophy (Figure 5-21).
Latency differences between eyes n a given patient
O.D.
may indcate optic nerve demyelination, as is found
n mltiple sclerosis (Figure 5-22).
o.s. Another type of VEP s that of pattern stimul of
black and white checks that exchange places at a
rapid rate: The black checks become white and vice
normal latency for each eye and normal amplitude for the right eye
(oculus dexter [O.D.]) but reduced amplitude for the left eye (oculus versa, as in Sherman's procedure.51 The sustained
sinister [O.S.]), as in optic atrophy. response with this type of VEP allows assessment of
ChapterS 159

visual acuity and aids n the diagnosis and prognosis O.D


of amblyopia. The VEP recording of each eye can be
compared for differences in visual acuity to help
establish the diagnosis of amblyopia in the absence of
an organic lesin, particularly in those patients who
do not respond reliably to optotype acuity tests. Fig-
ure 5-23 illustrates how visual acuity is estimated by
looking at the peak VEP amplitude for different spatial
frequency checkerboard patterns. It is a common
clinical observation that VEP acuity is often superior
to that found using optotype n cases of amblyopia.
We consider this observation to be a favorable prog-
nostic sign. This suggests that there s sensory poten-
tial for the improvement of visual acuity, often to the
level indicated by the VEP. Besides the sensory reduc-
tion of acuity, amblyopes often have a motor disorder
(e.g., EF). The VEP reveis the visual acuity indepen-
dent of the aiming error in the amblyopic eye.

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

TABLE 5-6. Classification of Centricity of Fixation

Central fixation Fovea I Parafoveal (between


Eccentric fixation (EF) fovea and 2 degrees EF)
Macular (2-5 degrees EF)
Peripheral (beyond 5
degrees EF)

tricity in which the fixation point s based on the


time-averaged position of an eye.
A description of EF ncludes reference to the
direction and distance from the fovea to the eccen-
tric point (or time-averaged position) located on
the retina. The direction of EF s referred to one of
FIGURE 5-24SITE IRAS Interferometer. (Courtesy of Bernell Corpo-
eight quadrants: nasal, temporal, superior, inferior,
ration.) superonasal, inferonasal, superotemporal, and
inferotemporal. We have found that nasal EF s
generally the rule n strabismic amblyopia, particu-
Ciuffreda et al.12 considered EF to be caused, n larly esotropa, and often has a vertical compo-
many cases, by a shift in sensory spatial direction nent, although it s smaller than the horizontal
away from the fovea and probably was related to component. Temporal EF is the exception in stra-
the impaired directional sense found in the central bismic amblyopia, even n exotropia.
retina of amblyopic eyes. Bedell and Flom35 found Unsteadiness of fixation can be associated with
monocular spatial distortion, spatial uncertainty, central or eccentric fixation. It s clinically relevant
and direction error to be associated with strabis- to describe the amplitude of unsteadiness if it exists.
mic amblyopia. Monocular spatial distortion can The degree of unsteadiness is indicated as a plus-
be described as a monocular asymmetry in spatial or-minus amplitude from the fixation locus (time-
vales between nasal and temporal retinal loci. averaged position): for example, 3 degrees nasal,
This sensory spatial asymmetry and uncertainty unsteady (1 degree) EF. A more common clinical
results in a motor fixation pattern n which the way of recording this would be unsteady, nasal, 3-
time-averaged position of the fovea s off the fixa- degree EF 1 degree. Note that many clinicians
tion target and appears unsteady. record EF magnitude and amplitude of unsteadiness
n prism diopters rather than in degrees.
Description of Eccentric Fixation
The fixation pattern of an amblyopic eye is Visuoscopy
described with reference to the centricity, direc- Visuoscopy (formerly known as vsuscopy) for
tion, and degree of steadiness. The classifcatin evaluating fixation s accomplished by using an
provided in Table 5-6 can be used to describe cen- ophthalmoscope with a graduated reticule in
place. The doctor observes a projected image of

FIGURE 5-25Typical orientations of grating targets


n lser and nonlaser interferometers.
Chapter 5 161

the reticule on the patient's fundus while the a.


patient s asked to look directly at the center of
the projected pattern and to hold fixation as
steadily as possible. (Figure 5-26 llustrates com-
monly used retcules.)The separations n reticules
are generally of a magnitude representing 1A. This
can be verified by projecting the target onto a
wall at a distance of 1 m, at which each separa-
tion (e.g., circle) would be 1 cm apart. Because
fixation must be tested under monocular condi-
tions, one eye of the patient must be occluded
during testing. A practical way of accomplishing
this is by asking the patient to cover the nontested b.
eye with a hand or an occluder. For very small
pupils, dilation (with mydriatic drops) s often
necessary to lcate the fovea and make visuo-
scopic observations. A dilated fundus examina-
tion should be performed initially n any case of
suspected amblyopia, to rule out organic lesions;
this s a convenient time during which to perform
visuoscopy.
During visuoscopy, four clinical observations
are routinely made:
1. Do the fovea and macular reas look nor
mal? The clinician must carefully inspect the c.
fovea and macula for lesions and develop-
mental anomalies. Is there a well-defined
foveal light reflex? Are there mltiple
reflexes? If either rea appears abnormal n
any way, then a 60- or 90-D lens examina-
tion on a slit lamp s recommended to rule
out or identify an organic lesin. .
2. Is there central or eccentric fixation? If EF
s present, what s the direction and mag
nitude?
3. Is there steady or unsteady fixation? If FIGURE 5-26Examples of reticules of direct ophthalmoscopes for
unsteady fixation s present, what are the visuoscopy. a. Welch-Allyn. b. Propper. c. Keeler. These direct oph-
thalmoscopes are available from local suppliers of ophthalmic
amplitude and type of oscillations? nstruments.
4. Is there faulty localizaron associated with
EF?
Figure 5-27 depicts examples of the visuo- position and steadiness of the fovea as the patient
scopic patterns of fixation in different cases of EF attempts to fixate a target. The phenomenon is more
and their associated clinical description. These correctly called Haidinger's brushes (plural), but cli-
examples for the right eye depict nasal and infe- nicians refer to the entoptic image as a brush. Sev-
rior EF, with the fovea (represented by the starlike eral instruments are available for producing a
spot) being temporal to the fixated center of the Haidinger brush, but the most practical, we believe,
visuoscopic reticule. is the Bernell Macular Integrity Tester-Trainer (MITT)
(Figure 5-28). This instrument has a motor-driven,
Haidinger Brush Testing
rotating, polarized filter behind a transparent slide
The Haidinger brush is a retinal entoptic phenome-
imprinted with fixation targets. Perception of the
non that can be used clinically to indcate whether
Haidinger brush requires the patient to look at the
the fovea s functionally intact and to determine the
rotating polarized filter through a deep cobalt-blue
162 Chapter 5
i
RIGHT EYE

b.
HAIDINGER'S BRUSHES (H.B.)
(PERCEIVED BY PATIENT).

PATIENT USES POINTER


TO INDCATE WHEHE HE
PERCEIVES THE H.B.

HAIDINQER-S BRUSHES (H.B.)


(PERCEIVED BY
PATIENT)
FIXATION
SPOT

PATIENT USES
POINTER TO INDCATE
WHERE HE PERCEIVES
THE H.B.

FIGURE 5-28The Bernell Macular Integrity Tester-Trainer. a. Draw-


ing of the nstrument; clear slide with fixation spots placed before the
illuminated circular window. b. Example of central fixation, n which
case the patient sees the Haidinger brush and the fixation spot as
superimposed. c. Example of eccentric fixation, whereby the Haid-
inger brush and the fixation spot are not superimposed. This response
would indcate nasal eccentric fixation of the right eye. If this
response were found when testing the left eye, temporal eccentric fix-
ation would be indicated.

fovea, the center of the perceived pattern represents


FIGURE 5-27Visuoscopic patterns of fixation in an example of right the center of the fovea.
eye being tested. a. Central fixation. b. Parafoveal eccentric fixation. In cases of amblyopia, the perception of the
c. Eccentric fixation within the macular rea. d. Peripheral. The direc-
tion of eccentric fixation n these examples is nasal and inferior (.e., Haidinger brush somet mes is difficult to elicit. Evo-
projected grid is down and in front of the fovea [asterisk]). cation of perception of the entoptc phenomenon in
the amblyopc eye represents a good prognostc
sgn. The fovea then is considered to be functionally
ntact and, practically speaking, a foveal tag is avail-
filter n front of the eye being tested. This is a
able for training for proper foveal fixation reflexes.
monocular technique; the nontested eye is occluded.
Lack of perception of the Haidinger brush does not
The patient should see a brushlike propeller that
necessarily mean the macula s dysfunctional or dis-
appears to radate from, and to rotate about, the
eased. Some individuis with normal retinas have
point of foveal fixation. The entoptic image of the
difficulty seeing this entoptic image. An amblyope
fovea is believed to be caused by double refraction
may have a particular problem seeing the brush if
by the radially oriented fibers of Henle around the
53 there is EF, because t does not appear where the
fovea. Because these radial fibers converge on the
patient is fixating. The straight-ahead direction s
Chapter 5 163

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

TARGET MOVED BASE-OUT


VISUAL AXIS
LINE OF THE
SUBJECTIVE ANGLE
OF DEVIATION

A-0

V. FOVEA AND
POINT "a"
COINCIDENT

FIGURE 5-31The angle of anomaly (A), in which thefovea (f)of the


ieft eye corresponds to point a of the right eye. Angle A is subtended at
the center of rotation of the eye by the visual axis and the line of the
subjective angle of deviation.

always precise, which necessitates the allowance for


measurement error. This s particularly so when the
patient is an uncooperative child or a poor observen
An example of NRC s illustrated n Figure 5-30.
TO OBJECTIVE ANGLE TO
ACHIEVE SUPERIMPOSITION Angles H and S are the same in this case of esotro-
pa with NRC:
A A
HCLRE 5-30Normal retinal correspondence. H = 25 (eso), S = 25 (eso)

Ihe term anomalous retinal correspondence is


used throughout this book, as s the traditionally In free-space natural viewing, diplopia s likely
lecognized abbreviation, ARC, although some pre- to occur when there s a strabismus of recent onset
fer the designation AC. and NRC. Point zero, the target point, is stimulated
peripherally and produces homonymous diplopia,
Oassification unless there s strong peripheral suppression. Sup-
ARC s an antidiplopic sensory adaptation that s pression is likely to take place at the fovea of the
prevalent in developmental strabismus. Its presence deviating eye to prevent overlapping of the two dif-
indicates a significant difference between the hori- ferent foveal images (.e., confusin). ARC would
zontal objective angle of deviation (H) and the sub- be the more parsimonious antidiplopic adaptation,
jEctive angle of directionalization (S). The difference as there is the added advantage of preserving rudi-
between these two angles s the angle of anomaly mentary peripheral binocularity and, possibly, gross
(A). Some measurement error must be allowed; oth- stereopsis in small angles of strabismus. However,
erwise, a false-positive diagnosis may result (.e., a ARC can probably develop only in response to
diagnosis of ARC when actually there s normal reti- strabismus during early childhood when there is
nal correspondence [NRC]). In small-angle strabis- cortical plasticity with respect to binocular visual
A
mus, allowance of a 1-2 error may be necessary and direction.
A
upto 5 should be allowed for large angles of strabis- Three angles are involved n ARC. The follow-
mus when comparing H and S. The larger the strabis- ing relation between these angles applies: H = A
mus, therefore, the more allowance is made for + S or, solving for A, A = H - S. Angle A s the
measurement error. In theory, angles /-/and S should angle subtended at the center of rotation of the
be exactly the same in NRC (angle A being zero n eye by the fovea (f) and the anomalous associ-
magnitude). Clinical measurements, however, are not ated point (a) (Figure 5-31 ). The fovea of the fixat-
168 Chapter 5

TARGET AT ORTHO POSITION.


SUPERIMPOSITION OF TARGETS
DESPITE ESOTROPA

POINT "a" AND


POINT ZERO
COINCIDENT

PAT1ENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)

FIGURE 5-32Harmonious anomalous retinal


____ J correspondence. (f = fovea.)

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

ous ARC (UNHARC), n which H s larger than S, TARGET MOVED TO BASE-


OUT POSITION TO ACHIEVE
SUPERIMPOSITION
and point a lies between point fand point zero. In
the example of UNHARC provided n Figure 5-33,
the following vales apply:
H = 25A S=12A

Some relatively rare types of ARC that occur


secondary to changes in the angle of deviation
(H)can result n some unusual measurements of
the subjective angle (S). An example of paradoxi-
cal ARC type one s illustrated in Figure 5-34. In
such a case, the patient has a subjective angle
under binocular viewing conditions, as if there
were exotropia, even when H ndicates esotro- POINT "a"

pa. This condition often occurs when the origi-


nal angle of esotropa was greater before
extraocular muscle surgery than afterward. In this
example, the deviation was reduced by surgery,
but not sufficiently to make the visual axes paral-
lel. Assume that before surgery there had been
HARC, so that pont a was originally at point
zero. The outward rotational movement of the
deviating eye with surgery caused point a to be
moved from the ortho demand point to another
point farther n the nasal retina. Stimulation of
PATIENT'S
the postsurgical point zero, which s temporal in PERCEPTION
(CYCLOPEAN
respect to point a, causes S to be n the exo PHOJECTION)

direction. For example:


H = 25A (eso), S = -28A (exo) A =
25A - (-28A) example, may reduce an eso deviation, and minus
lenses may reduce an exo deviation. Prisms may
optically affect these angular relationships as
Paradoxical type two ARC often occurs after a well as the possibility that visin training tech-
surgical overcorrection of exotropia. For example, niques will produce changes. There appears to
a patient with an exotropic right eye and HARC be wide variation in the way that patients n
preoperatively may have an esotropic right eye whom HARC is the initial adaptation to their
postoperatively (Figure 5-35). Point a would be strabismus sensorially readapt to a new angle of
moved from point zero to a location temporal- deviation postoperatively or after optical and
ward n relation to point zero. Stimulation of training manipulations of the angle H. In some
point zero would then cause the patient's angle S cases, HARC and its consequent advantages to
to be more eso n direction than t was preopera- fusin re-establish themselves; at other times,
tively. (S s more eso n magnitude than is H.) For paradoxical ARC results, along with the undesir-
example: able, but fortunately rare, consequence of intrac-
table diplopia.
H= 17A(eso),S = 30A(eso)
In summary, then, the conceptual basis for the
X\ = 17A-30A
classifcatin of NRC and ARC s the location of
the anomalous associated point (a) in the deviating
Causes other than extraocular muscle surgery eye (Figure 5-36). If point a of the deviating eye is
may alter the magnitude of H to result n UNHARC anywhere other than at the fovea, then there s
or a paradoxical type of ARC. Plus lenses, for
170 Chapter 5

TARQET MOVED TO BASE-IN


POSITION TO ACHIEVE
SUPERIMPOSITION

FIGURE 5-34Paradoxical type one unharmonious


anomalous retinal correspondence. (f = fovea.)

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

TARGET MOVED TO BASE-OUT POSITION


BEYOND OBJECTIVE ANGLE TO ACHIEVE
SUPERIMPOSITION

POINT '

PATIENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)

: 5-35Paradoxical type two unharmonious anomalous


I cncrespondence. (f = fovea.)

HCLRE 5-36Anomalous retinal correspondence


MH classification based on the location of point a,
fecated by arrows pointing to the retinal site on the
. (HARC = harmonious ARC; NRC = normal i fovea NRC
correspondence; PARC I, PARC II = paradoxi-cARC
type I, type II [respectively]; UNHARC = UNHARC
PARC I
^i m i i n i i i i i i i A R C . )
HARC
172 Chapter 5

melding or rivalry of colors as reported by patients


TABLE 5-7. Classifcatin of Normal and Anomalous having normal binocular visin, but centrally, ARC
Corresponde/ice by Mathematic Formulas patients often describe a split bipartite field in
which half is purely red and half purely green. If
NRC the red filter happens to be on the right eye and the
H = S; A = O
ARC green on the left, the patient reports seeing the red
HARC hemifield to the right and the green to the left.
H = A; S = O
UNHARC Sometimes a patient will report a seam running
H>S;H>A
PARC! down the middle of the split field (Figure 5-39).
A >H; 5 opposite direction
These central reas of pur colors represent
to H (S <0)
PARC U monocular processing of visual information by
S >H; A opposite direction to H (A <0)
each eye within the regin between the visual axes
A = angle of anomaly; ARC = anomalous retina! correspon- under these conditions. Patients with ARC often
dence; H == objective angle of deviation; HARC = harmonous
ARC; NRC = normal retinal correspondence; R&RC I (11) = para-
are described as having peripheral fusin, the
doxical ARC type one (two); S = subjecflve angle of directional- implication being that there is no central fusin.
iiation; UNHARC unharmonious ARC. The Swann split-field effect is an important exam-
ple that supports this interpretation of the status of
binocularity in strabismic patients having ARC.
ARC appears to be more prevalent in patients
Another remarkable feature of the ARC horopter is having small and modrate angles of constant stra-
its abrupt and radical change in direction within the bismus (e.g., 30A or less) as compared with those
space subtended between the visual axes (see Figure who have larger angles.66'67 Some patients with
5-37c). Flom65 referred to this rea as the "notch" in small deviations, usually less than 10A, show con-
the horopter. One might ask how the patient pro- siderable sensory fusin capability. It is not
cesses binocular information within the visual unusual to find 200 seconds of stereopsis testing
axes when the horopter is so extremely skewed. with the Titmus animis stereograms but poorer
One possible notion is that this rea between the axes stereoacuity, if any, with the Wirt circles and
s not binocular at all under normal viewing condi- hardly any with random dot stereograms. Also,
tions. A skew in the identical visual direction fusiona! vergence ranges may be fairly normal,
horopter in nonstrabismic subjects usually means particularly f prism demands are introduced at a
there is aniseikonia, and the greater the skew, the slower rate than in routine vergence testing.68 Pre-
greater is the aniseikonia. The radical skew of the sumably, peripherally sized targets allow for possi-
central portion of the ARC horopter might mean that ble motor fusin. In cases of small-angle esotropa
aniseikonia is too extreme to allow binocular dispari- with ARC, there is a small notch in the horopter so
ties to be processed. In this case, the patient may be that the overall shape, location, and thickness of
said to have no central fusin, and the visual infor- the singleness horopter appears nearly normal (see
mation within the axes is processed monocularly. Figure 5-37d). These clinical observations are con-
Furthermore, there is usually suppression in the notch sistent with the theoretical concept of peripheral
rea subtended by the angle between the fovea and fusin and central suppression as a general mecha-
the target point of the deviating eye. nism in ARC, whereby the size of the angle of devi-
This interpretad o n may help to explain the ation determines, in part, the binocular capabilities
observation by strabismic ARC patients of the of the strabismic patient.
Swann split-field effect. Red-green glasses are
worn by a nonstrabismic subject, and he or she Horror Fusionis
views a detailed target against a white background Hofstetter et al. 1 define horror fusionis as "the
(Figure 5-38). The usual report in nonstrabismic inability to obtain binocular fusin or superimposi-
patients is color fusin (a murky brown) and color tion of haploscopically presented targets, or the
rivalry (a percept of alternating, moving red and condition or phenomenon itself, occurring fre-
green reas). However, many ARC esotropic quently as a characteristic in strabismus, in which
patients report a different percept under similar case the targets approaching superimposition may
conditions. Peripherally, there appears to be the seem to slide or jump past each other without
apparent fusin or suppression." In the past, horror
Chapter 5 173

Singleness
Horopter

Horopter (NRC
Horopter)

R. zero
Identical
Visual
Direction
Horopter

b.

IVD horopter

R. zero

FIGURE 5-37Idntica! visual direction (IVD) horopter. a. Bifixating person, in whom the horopter passes through the centration point and th e
location of the target. b. Esotropic person with normal retinal correspondence (NRC), n whom the identical visual direction horopter passes
through the centration point but not through the location of the target. c. Esotropic person with harmonious anornalous 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

innate.74 ARC is an acquired sensory adaptation to


strabismus during early development, when the cor-
tex is still malleable and capable of establishing a
Chapter 5 175

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

FIGURE 5-40Afterimage generators. a. Camera flash attach-


ment. b. Homemade device using light bulb and a mask.

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.

Interpretaron of results s made by


measuring the displacement of the vertical
Al from the central gap of the horizontal Al. If
the patient reports seeing a perfect cross,
there s presumption of NRC, as this
represents an angle A of zero (Figure 5-41).
Whether the eyes are straight (ortho posture)
is irrelevant f a perfect cross s perceived
and reported: Each fovea was stimulated; if
there is normal correspondence between
the two foveas, a cross will be perceived
regardless of the direction n which each eye
s positioned.
An example of a noncross perception s
shown n Figure 5-42. The right eye is
esotropic with ARC. Point a s the
representational point that corre-sponds to
the fovea of the left eye. Cyclopean pro-
jection shows the vertical Al being visual
ized to
178 Chapter 5

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.

FIGURE 5-42Example of harmo-


nious anomalous retinal correspon-
dence. (f = fovea; O.D. = oculus
dexter; O.S. = oculus sinister.)

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

FIGURE 5-45Combination of the Haidinger brush


(HB) superimposed on the black dot (seen by left eye)
and a vertical afterimage (A.I.; also seen by left eye but
transferred from the right eye). Flashing light near right
eye enhances the transferred afterimage seen by the left
eye. (MITT = Bernell Macular IntegrityTester-Trainer.)

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 PERCEIVES STAR STAR SEEN BY DOCTOR


PROJECTED UPON PATIENTS PROJECTED ONTO
FUNDUS PATIENTS FUNDUS

MIRROR (OR B.O. PRISM)

DOCTOR SUSPENDS
VISION IN O.S.

ISUSCOPE WITH DOCTOR SUSPENDS


STAR QRATICULE VISION IN O.S.

O.S. FOVEA O.D. FOVEA


PATIENT PEHCEIVES STAR PATIENTS PERCEPTION
AND/OR FIXATION LIQHT; (CVCLOPEAN PROJECTION)
RELATIVE POSITION OF
EACH DEPENDENT UPON
CORRESPONDENCE.

C.

STAR SEEN BY DOCTOR


PHOJECTED ONTO
PATIENTS FUNDUS

d.
STAR SEEN BV DOCTOR
PROJECTED ONTO
PATIENTS FUNDUS
STAR QRATICULE
IN VISUSCOPE
STAR GRATICULE
IN VISUSCOPE

DOCTOR SUSPENDS
VISION IN O.S.

O.S. FOVEA DOCTOR SUSPENDS VISION IN


O.S. rO.O. FOVEA
O.S. FOVEA
PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION) -- PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)

FIGURE 5-46The bifoveal test of Cppers. a. Doctor's right eye views the patient's right eye by means of visuoscopy. The star is seen by the doctor
and the patient. An angled mirror (or a large base-out [B.O.] prism) before the patient's left eye avoids obstruction to seeing by the left eye. b. Exam-
ple of normal correspondence. c. Example of anomalous correspondence. d. Star must be projected onto point a in order for a 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

O D. Fundus mination for each tube also is adjusted by


18% setting the rheostat to approximately 8.
2. First-degree targets that are central in size
FIGURE 5-47Useful are used (see Figure 5-6). For example, the
dimensions of the X target may be placed in one tube and the
fundus for estimating
square target in the other. The patient is
Temporal instructed always to look at the center of
disc
margin each target.
3. Each tube light is alternately doused
Center of
optic disc (occluded) by means of the two small but-
Nasal disc
margin
ton switches near the front of the control
the magnitude of the
panel. The altrnate dousing of each target
angle of anomaly when makes this an altrnate cover test in an
using the bifoveal test. instrument rather than in true space.
(O.D. = oculus dexter.)
4. The examiner neutralizes the lateral movement
of the eyes by adjusting the position of the
tube of the patient's nondominant eye. Mean-
(assuming the dominant eye s centrally fixating, while, the tube for the dominant eye is main
which s almost always the case). This is because tained on zero (primary position of gaze).
testing is done under binocular conditions, When the conjgate movement is neutralized
thereby vitiating any effect of EF that would other- using a bracketing technique, the objective
wise come into play if testing were performed angle (H) is determined. The magnitude is
under monocular conditions. The disadvantage of read directly from the prism diopter scale.
the bifoveal visuoscopic test is that a high level of The direction of the deviation (eso or exo) s
patient cooperation must be maintained; other- noted by observing the final positions of the
wise, either testing is impossible or results are tubes, as illustrated in Figure 5-5.
unreliable. Testing is sometimes not feasible n
young children. Hirschberg testing can also be performed with a
Synoptophore by observing the positions of the
Major Amblyoscope corneal reflections of the light from the two tubes.
The major amblyoscope can be used to detect and This method is particularly appropriate for deter-
calclate angle A. The Synoptophore (see Figure mining angle H when amblyopia is present in one
5-4) has a long history in the field of strabismus eye and monocular fixation is inaccurate. For this
diagnosis and therapy and is still n use today. Each procedure, the instrument's lights should be turned
tube of the Synoptophore has a mirror placed at 45 up to the mximum intensity and the room lights
degrees and a +7-D eyepiece lens. Test targets are dimmed. The patient must be properly positioned
placed at optical infinity. (Sketches showing the so that the examiner has a good view of the
direction of movement of the carriage arm to cr- patient's eyes to judge the positions of the corneal
ate horizontal prismatic demands are presented in light reflexes. The accuracy of the procedure is lim-
Figure 5-5.) ited to approximately 5 A. A recommended proce-
The procedure for measuring the objective angle dure follows:
of deviation (called the altrnate exclusin method) 1. Only one target, placed before the domi
using this instrument is as follows: nant eye, is used, and the patient's fixation
1. The main power switch is turned on, and is directed to the center of that target (e.g.,
the patient is instructed to look into the the fish target). The tube must be main
instrument. The chin and forehead rests and tained in the primary position (zero on the
the interpupillary distance setting are scale).
adjusted properly for the patient. The illu- 2. Angle kappa (K) of the fixating eye is esti-
mated. The tube of the nondominant eye is
adjusted so that the corneal reflection is in
the same relative position in each eye. (The
position of the reflex should look like angle
Chapter 5 183

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

SEEN BY LEFT EYE


SEEN BY RIGHT EYE

FIGURE 5-48Bagolini striated lenses with visible streaks, causing an


C.
effect analogous to Maddox rods. (Photo courtesy of Bernell Corpora-
tion.)

will report seeing the lights above the intersection of


the streaks (see Figure 5-49f). In contrast, an exotro-
pic patient with heteronymous diplopia would be
expected to report seeing the lights below the inter- e.
section (see Figure 5-49g).
The preceding exampls presume NRC. However, \
f an esotrope has ARC of the harmonious type, the
patient is expected to report seeing one light centered
n the intersection of the streaks (see Figure 5-49c), as
would a patient who s nonstrabismic and bifixating.
The reason for the strabismic's apparently normal
response is that angle S is zero n HARC. The clini- f.
cian will not be misled f the manifest deviation is
observed while listening to the patient's report of see-
ing the light centered at the intersection of the two
streaks. This is obviously a case of ARC, because S is
zero and H is of a conspicuous magnitude. If, how-
ever, the strabismus is small and difficult to detect by
direct observation, the unilateral cover test is neces-
sary. (This is analogous to the douse target test using
the major amblyoscope.) The clinician watches for
any movement of the uncovered nondominant eye
when the dominant eye s occluded. A significant
movement means that H is greater than zero, which
confirms the presence of ARC.
86
von Noorden and Maumenee suggested that .
the Bagolini test is not useful in diagnosing cases
of UNHARC in which 5 s a magnitude other than
zero. We believe, however, that the following pro - is any significant movement. In this case, S s equal
cedure is useful n UNHARC cases. The examiner to the base-out prism power necessary for attain-
begins by finding out from the patient where the ment of the centered pattern. (When the patient is
streaks intersect. If they cross below the lights, as strabismic and S s not zero, the ARC is unharmo-
n an eso deviation, base-out prism s increasingly nious.) The estimated magnitude of A is repre-
introduced until the patient reports that the light s sented by the magnitude of the movement of the
centered at the intersection of the streaks. At this uncovered eye on the unilateral cover test during
time, the unilateral cover test is conducted to
determine whether there is any movement of the
uncovered eye. The patient has UNHARC if there
Chapter 5 185

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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66. Flom MC. Treatment of Binocular Anomalies in Children. 80. Flom MC, Kerr KE. Determination of retinal correspon
In: Vision of Children. Hirsch MJ, Wick RE, eds. Philadel- dence, multiple-testing results and the depth of anomaly
phia: Chilln; 1963:197-228. concept. Arch Ophthalmol. 1967;77:200-213.
67. Burian HM, Luke N. Sensory retinal relationships in 100 81. Bagolini B, Tittarelli R. Sensorio-motorial anomalies in
consecutive cases of heterotropia. A comparative clinical strabismus (anomalous movements). Doc Ophthalmol.
study. Arch Ophthalmol. 1970;84:16. 1976;41:23.
68. Burian HM. Fusional movements in permanent strabis- 82. Enos MV. Anomalous correspondence. Am J Ophthalmol.
mus. A study of the role of the central and peripheral reti 1950;33:1907-1913.
nal regions in the act of binocular visin in squint. Arch 83. Hugonnier R, Hugonnier S, Troutman S. Strabismus, Het-
Ophthalmol. 1941;26:626. erophoria, Ocular Motor Paralysis. St. Louis: Mosby;
69. Lyle TK, Wybar K. Practical Orthoptics in the Treatment of 1969:199.
Squint, 5th ed. Springfield, III.: Charles CThomas; 1967:617. 84. Flom MC. A mnimum strabismus examination. J Am
70. Kramer M. Clinical Orthoptics, 2nd ed. St. Louis: Mosby; Optom Assoc. 1956;27:642-649.
1953:337. 85. Cheng D, Woo GC, Irving EL, et al. Scattering properties
71. Krimsky E. The Management of Binocular Imbalance. of Bagolini lenses and their effects on spatial visin. Oph-
Philadelphia: Lea & Febiger; 1948:204. thalmic Physiol Opt. 1998;18:438-445.
72. Bielschowsky A. Congenital and acquired deficiencies of 86. von Noorden GK, Maumenee A. Atlas of Strabismus. St.
fusin. Am J Ophthalmol. 1935;1 8:925-937. Louis: Mosby; 1967:84.
chaptere / Diagnosis and Prognosis

Establishing a Diagnosis 189 Otfier Approaches 206 Case


Prognosis 190 Functional Cure of Examples 206 Poor
Strabismus 190 Prognosis 206
Prognostic Variables of the Case 1 206
Deviation 194 Case 2 207
Associated Conditions 194 Case 3 208 Poor to Fair
OtherFactors 196 Cosmetic Cure Prognosis 208
of Strabismus 197 Heterophoria Case 4 208
198 Modes of Vision Therapy 199 Case 5 209 Fair
Lenses 199 Prisms 200 Occlusion Prognosis 209
200 Vision Training 201 Extraocular Case 6 209 Fair to Good
Muscle Surgeiy 201 Prognosis 210
General Approach 201 Case 7 210
Adjustable Suture Procedure 203 Case 8 210
Surgical Considerations 203 Case 9 210 Good
Pharmacologic Treatment 204 Prognosis 211
Botulinum Toxin 205 CaselO 211
Case 11 211
Case 12 212

A valid prognosis cannot be made unless there is a ESTABLISHING A DIAGNOSIS


complete diagnosis. Most of this chapter s devoted to
The first part of a complete diagnosis of Strabismus
the diagnosis and prognosis of Strabismus rather than
s the test results of each of the nine variables of
of heterophoria, because there is a ful I range of prog-
deviation of the visual axes: comitancy, frequency,
nosis, from poor to good, in cases of Strabismus (Table direction, magnitude, accommodative-convergence/
6-1). In contrast, the prognostic range in cases of het- accommodation (AC/A) ratio, variability, cosmesis,
erophoria is more limited because there are relatively eye laterality, and eye dominancy. The next part
few complications (e.g., anomalous retinal correspon- includes associated conditions: suppression, ambly-
dence [ARC], lack of fusional vergence, and deep and opia, abnormal fixation, ARC, horror fusionis, and
extensive suppression) that adversely affect successful any visual skills inefficiencies.
treatment. Because the prognosis for achieving a A case history also helps establish the exact
functional cure s generally good, only a brief discus- diagnosis and is necessary for a valid prognosis.
sion s given to the prognosis of heterophoria. Furthermore, time of onset, mode of onset, and
190 Chapter 6

therapy for many years.1 Flom's criteria made feasi-


TABLE 6-7. Range o Prognosis in Strabismus and ble the comparison of results from various studies.
Chance ofFunctional Cure Flom,2 however, later modified the criteria for clini-
cal purposes. In the past, the criteria for functional
Chance of Functional Cure (%)
cure of strabismus, according to Flom,1 included the
Prognosis
presence of clear, comfortable, single, binocular
Poor 0-20 visin at all distances, from the farpoint to a normal
Poor to fair 21-40 nearpoint of convergence. There should be stereop-
Fair 61-80 sis, although Flom1 did not specify the stereoacuity
Fair to good
81-100 threshold. The patient also should achieve normal
Good
ranges of motor fusin. The deviation may be mani-
fest up to 1% of the time, providing that the patient
is aware of diplopia whenever this happens (i.e.,
patient knows the deviation is not latent but is man-
duration of strabismus, refractive history, treat- ifest at that time). This should mean that the strabis-
ment given, and developmenta! history of the mus may occur only approximately 5-10 minutes
patient are all vitally important in determining the per day and that the patient has clear, single, com-
prognosis. The doctor must also assess the results fortable binocular visin during the rest of his or her
of additional evaluative procedures such as prism normal waking hours. Corrective lenses and small
adaptation, special cover testing, vertical and amounts of prism may be worn, but prismatic
cyclo deviation testing, prolonged occlusion, and power is limited to 5A. In a later publication, Flom2
testing for sensory fusin at the centration point. dropped the requirement for stereopsis, diplopia
A good diagnostic statement is not a listing of clin- awareness, normal ranges of motor fusin, and the
ical data but rather a succinct and understandable limit of 5A, stating that "a reasonable amount of
account that includes the distinguishing features and prism" meets the criteria.
nature of the condition. The diagnostic statement Flom usted another category of cure that he
must be well written in clinical records and reports, called almost cured. The criteria for this classifica-
not only for conceptual clarity but also for medicole- tion allow for stereopsis to be lacking and for the
gal purposes. One acid test of a good diagnostic deviation to be manifest up to 5% of the time.
statement is whether it can be communicated com- Fairly large amounts of prism may be used as long
pletely and concisely. Examples are given in this as there is comfortable binocular visin. The
chapter to Ilstrate succinct diagnostic clarity. remaining criteria for functional cure must be met.
The third category was called modrate improve-
ment The stipulation here was that there must be
PROGNOSIS improvement in more than one defect. Flom's
fourth category of cure was s//ghimprovement,
Prognosis is the prediction for success by a specified
which indicated improvement in only one defect
means of treatment. As to binocular anomalies,
(e.g., amblyopia reduced). A final category was
prognosis pertains to the chance for a favorable out-
that of no improvement as a result of therapy.
come by the use of tenses, prisms, occlusion, visin
Flom's current criteria for functional cure are as
training, surgery, medication, mental effort, or any
follows: (1) maintenance of bifoveal fixation in the
combination of these methods of treatment. After all
ordinary situations of life 99% of the time; (2) clear
necessary testing has been completed and a thor-
visin that is generally comfortable; (3) bifixation
ough diagnosis has been made, the doctor makes a
in all fields of gaze and distances as cise as a few
prognosis of the case. From this, appropriate recom-
centimeters from the eyes; and (4) wearing of cor-
mendations for the patient can be made. There are
rective lenses and a reasonable amount of prism.2
two types of prognoses depending on the goal of
We concur with the new cure criteria set forth
treatment. The doctor can describe the chances for
by Flom,2 in which his former category of almost
either a functional cure or a cosmetic cure.
cured can be incorporated. We also recommend
keeping Flom's categories of modrate improve-
Functional Cure of Strabismus ment and slght improvement.
The Flom criteria for functional cure of strabismus Although not included within the stated cure cri-
has been the standard for assessing success in visin teria, we believe the level of stereopsis is clinically
Chapter 6 191

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 6-2. Classification of Strabismus According to


Time of Onset and Prognosis for Functonal Cure TABLE 6-3. General Rules for Prognosis for
Functonal Cure of Strabismus by Means of
Vision Therapy
Type Prognosis

Poor (unless early surgery) Favorable factors


InfantHe (oreetat4-6 mos
of age or earlier) Acquired Fair (depending on cir- Good cooperation
(onset after 6 mos of age) cumstances and ther-apy Intermittent strabismus
Nortaccommodative used) Good (unless Exotropia rather than esotropa
Accommodative strabismus of long Small rather than large angles of deviation
duration) Comitancy rather than noncomitancy
Family history of strabismus
Patient's age between 7 and 11 yrs
Late onset
Early treatment
Strabismus of short duration
Unfavorable factors
many cases, the etiology of this type of strabis- Eccentric fixaton
mus remains uncertain. Some causes are clini- Amblyopia in esotropa (but not as bad in exotropia)
cally well established. For example, a sensory Cyclotropia
obstacle to fusin, such as a unilateral cataract Anomalous retina! correspondence in esotropa (but
or anisometropia, usually results in an esotropa not an unfavorable factor in exotropia)
in young children. In contrast, exotropia is likely No motor fusin range {unfavorable in esotropa but
in older individuis with sensory obstacles to not unfavorable in exotropia)
fusin. Psychogenic causes of strabismus can Suppression n esotropa (but not as bad in exotropia)
also occur; these cases are almost always esotro- Constant strabismus
pic, although psychogenic exotropia is possible. Early onset
For example, an emotionally disturbed child Delay of treatment
with a large exophoria may learn how to let his Strabismus of long duration
or her deviation become manifest, purposefully, Source: Modified from MC Florn. The prognosis in strabismus.
for the sake of gaining attention, recognition, or AmJ Optotn Arch Am Acad Optotn. 19S8;35:509-514; and MC
sympathy. Flom. tssues in the Clnical Management of Binocular Anomalies. In:
Principies and Practce of Pediatric Optometry. AA Rosen-bloom,
Accommodative strabismus is usually esotro- MW Morgan, eds. Phladelphia; Lippncott; 1990:242.
pic, often due to uncorrected hyperopia and a
high AC/A ratio. However, mere can be accom-
modative exotropia in cases of divergence excess.
This is the condition in which the exo deviation at patient in whom the onset of strabismus was at
far is much greater than the exo deviation at near, age 1 year. Many years of untreated constant
indicating a high AC/A ratio. For example, a esotropa make t almost impossible to effect a
patient with uncorrected modrate hyperopia functional cure by means of therapy. When opti-
may be orthophoric at near but exotropic at far. cal therapy is applied later in Ufe, a microesotro-
This, therefore, can be thought of as an indirect pia may be the best result that can be attained.
type of accommodative strabismus. Bifoveal fixation achieved in such cases of long
The prognosis in most cases of accommodative duration is the exception. In some cases of
strabismus is usually good, provided that effec- untreated accommodative esotropa, the magn-
tive treatment is administered without delay. tude of the esotropa increases over time;
Constant strabismus of long duration makes the extraocular muscle surgery may be recom -
prognosis considerably worse. If the sensory mended for cosmetic mprovement.
adaptive anomalies (e.g., suppression, amblyopia, The reports on prognosis n strabismus by
or ARC) become deeply embedded, the prognosis Flom1'2 included certan factors that he found to
may be only fair or even poor: An example of a be favorable and others that he found to be unfa-
deteriorated accommodative esotropa is the vorable for functonal cure. A modification of ths
Chapter 6 193

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

and other factors, and then use professional judg-


194 ment to arrive at the most correct prognosis
for the patient. This requires an tem analysis
of each factor in the prognosis and evaluation of
the total combined effect (possible only after difficult, therefore, to make prognostic generaliza-
I
extensive clinical experience). tions about the AC/A ratio.
Variability of the deviation may be favorable if
Prognostic Variables of the Deviation the magnitude of the deviation changes from time
An important prognostic factor is the direction of to time. As regards the sensory aspect, variation in
the deviation. Exo deviations are ordinarily easier the magnitude may keep suppression and ARC
from becoming too deeply embedded, but such an
to treat than are eso deviations. Vertical deviations
outcome cannot be assumed in many cases. As
present more of a challenge, and treating torsional
regards the motor aspect, however, a widely vary-
deviations is even more difficult.
ing magnitude can be a surgeon's nightmare.
In regard to frequency of the deviation, there is
Similarly, the factor of cosmesis can be a bless-
general agreement that an intermittent strabismus
has a more favorable prognosis than a constant ing or a curse. If cosmesis is good, this is a blessing
for the patient. However, this causes complacency
strabismus. However, there are differences in
favorability from one intermittent case to another. and is often the reason patients do not enthusiasti-
A deviation that is manifest 95% of the time is cally seek a functional cure, which creates prob-
obviously more difficult to treat than one that is lems for the doctor treating the strabismus.
present 5% of the time. The less time the deviation As to eye laterality, traditional thinking is that
is present, the better is the prognosis. treatment of an alternating strabismus is more diffi-
cult than is treatment of a unilateral condition. This
The factor of comitancy must be considered.
conclusin has been prevalent because altrnate
Comitant strabismus generally is regarded to carry a
fixation is common in cases of infantile esotropa.
better prognosis than noncomitant strabismus, but
Findings in this group of patients have led to equat-
many exceptions may occur. Noncomitancy caused
ing alternaton with poor prognosis. Most recent
by a recently acquired paresis in which remission is
highly likely would not follow the general rule; the studies show that alternation s not a deterrent to a
good prognosis and may be slightly favorable
outcome in such a case is usually favorable if the
patient's condition is managed properly. when all types of strabismus are considered.1'2 This
Although there is some correlation between the may be true in part because individuis with alter-
magnitude of the deviation and prognosis, the rela- nating strabismus do not become ambiyopes.
tionship is not always cise. It is generally assumed Eye dom'mancy is probably not a factor in stra-
that the larger the angle, the worse is the prognosis. bismus prognosis. However, it can be a consider-
ation in the strabismic's perceptual adjustment to
This rule, however, often is refuted in cases of small-
everyday seeing and may be related to certain eye-
angle strabismus. Wybar8 stated that "microtropia is
hand or eye-foot coordination tasks.
unlikely to prove responsive to therapeutic mea-
sures." Likewise, Parks9 concluded that the prognosis
for bifoveal fixation in the patient with monofixation Associated Conditions
pattern is poor. As with diagnostic variables of the deviation, it is
The effect of the AC/A ra/o must be considered difficult to pin down the influence of each of the
in regard to the particular case in question. Gener- associated conditions on the overa!I prognosis.
ally speaking, a normal AC/A ratio is more favor- Peripheral and deep suppresson may cause the
able than either a high or low ratio. However, a prognosis to be worse than would be the case for
high ratio can be either a blessing or a curse, central and shallow suppression. Although this is
depending on the circumstances. It may be the generally true, there are many exceptions. For
principal cause of esotropa at near or exotropia at instance, there could be an esotropa with ARC in
far. However, the mechanical advantage of a high which suppression is very shallow. The prognosis
AC/A ratio when wearing lenses may greatly may be poor because of the ARC despite the
reduce deviations (e.g., plus lenses for nearpoint apparent favorable factor of almost negligible sup-
esotropa and minus for farpoint exotropia). It is pression. Because there is always interplay among
the many factors that affect a prognosis, it is diffi-
cult to speak in terms of absolutes for any one fac-
tor. Generally speaking, though, suppression alone
is not considered highly unfavorable.
Chapter 6 195

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

the child s 6 years of age or older. Some patients Target at infinity


as young as 4 years may be cooperative, but rarely
will there be sufficient cooperation for complex
visin training techniques from those younger than
4 years.
Cure of farpoint strabismus s commonly more
difficult than cure of strabismus at near. Treatment
of convergence excess s typically easier than is
treatment of divergence insufficiency. Similarly,
convergence insufficiency (nearpoint exo probiem)
is less difficult to treat than is divergence excess
Ifarpoint exo probiem).
Proper refractive care may prevent some binocu-
lar anomalies in strabismics. In this regard, a history
of good visin care can be considered favorable to
the prognosis in many cases.

Cosmetic Cure of Strabismus


A fault of many reports n the literature is that no
distinction is made between functional and cos-
metic cure. Many ophthalmic surgeons label the
patient as cured simply because the eyes appear
straight. Studies purporting to give cosmetic cure
rates are unreliable, because this is a subjective
valu judgment for which each reprter uses his or
her own criteria.
Certain cosmetic factors have a great effect on the
appearance of the strabismic individual (e.g., IPD,
eyelid shape, epicanthal folds, facial shape, and
+2.50 D
symmetry). Another important factor s angle kappa
(technically, angle lambda). For example, a negative
angle kappa may make an individual with ortho-
phoria appear to have esotropa. Similarly, cosmesis
may be good in moderately large angles of strabis-
mus. For instance, a 15A esotrope with a positive
angle kappa may appear to have no strabismus.
Because of the various combinations of cosmetic
FIGURE 6-1Centration point illustration n example of 15A esotropa.
factors affecting the appearance of the individual, a. Angle H of 15A esotropa of the rght eye (esotropa at 6 m, optical
there are no hard and fast rules relating the magni- nfinity). b. Sensory ortho posture at 40 cm with addition of +2.50-D
tude of strabismus to cosmesis. In the majority of lenses to simlate optical infinity.
cases, however, we find that if the strabismic angle
is reduced to 10A or less, cosmesis usually is good.
The esotrope may get by with a larger angle, such as
patients. In contrast, cyclo devations are ordinarily
15A or 20A, before the deviation s noticeable. This is
not a cosmetic probiem unless they are extremely
because most people have a positive angle kappa,
large. In such cases, usually a vertical and a horizon-
which favors the appearance of esotropa. Con-
tal deviation are present. These vertical and horizon-
versely, an exotropia of the same magntude will
tal deviatons, and not the cyclotropia, are usually the
probably be quite noticeable.
cause of the poor cosmesis.
Hyper deviations of 5A or less are not noticeable.
When the goal s only for cosmetic acceptabilty
Deviations beyond 10A may be unsightly and present
and not for functional cure, the most frequently
a cosmetic probiem for patients and parents of young
used form of therapy s extraocular muscle surgery.
198 ChapterG

which becomes a significant problem with powers


a. greater than 15A. If, however, all the prism is con-
fined to the deviating eye, the problem of blurred
visin is removed. The patient wearing a Fresnel
prism may also object to the appearance of the lines
to a person looking at him or her. Thus, the use of
inverse prism may become impractical because of
c. the objectionable appearance.
In strabismic deviations of modrate magnitude
(see criteria Usted in Chapter 4) that are just beyond
the limit of cosmetic acceptance, a combined
method of direct and inverse prism application can
be tried. This is illustrated in Figure 6-2 in which the
right eye is esotropic (see Figure 6-2a). If a direct
FIGURE 6-2The use of prisms to improve cosmesis n an example of prism (base-out) is placed before the left eye, the
esotropa of the right eye. a. Noticeable esotropa of right eye. b. Base- dextroversion diminishes the esotropic appearance
out prisrn before the left eye causes the left eye to turn in and the right
eye out (dextroversion equal to magnitude of prism). c. Yoked prism
of the right eye (see Figure 6-2b). Inverse prism
with base-in before the right eye enhances cosmetic appearance (base-in) then is placed before the right eye (see Fig-
because of the shifting of the palpebral aperture toward the apex of ure 6-2c). Although there probably is no movement
the prism.
of the right eye because of suppression, the optical
effect of the prism (image shifted toward the apex)
further enhances the salutary cosmetic results. The
Lenses occasionally are used for this purpose, n the amount of prism power necessary in this procedure
form of single-vision lenses for the correction of is usually approximately 40% of the magnitude of
hyperopia. Plus additions (bifocals) generally serve the strabismus. For example, an esotropic deviation
no purpose n cases n which cosmesis s the sol of 20A would require 8A before each eye (i.e., yoked
concern. Minus adds for farpoint exotropia have prisms).
been used also, although this treatment method is Patients may be taught the tactic of controlling
not highly recommended because the cosmetic head movements or using specified positions of
gain is only transitory. Nothing s achieved in the gaze to minimize a cosmetically noticeable stra-
long run, because the cosmetic problem returns as bismus. This is applicable in cases of comitant as
soon as the individual relaxes accommodation or well as noncomitant strabismus. For example, sup-
the overcorrection is removed. Minus lenses do play pose a patient with 20 A of comitant constant
an important role, however, in certain cases of esotropa of the right eye wishes to appear to be
exotropia in which there is hope for functional cure. orthophoric during a Job interview. The effect of
Alignment of the visual axes helps to promote sen- "straight eyes" may be accomplished by the indi-
sory fusin. vidual by making a small dextroversion, such as
Inverse prisms have been used for cosmetic fixating on the interviewer's left ear, for example,
improvement, with limited success. The main prob- rather than looking directly into the interviewer's
lem is the thickness and weight factor of glass or face. Such advice can be helpful to patients in their
plstic prisms. Fresnel prisms eliminate these draw- occupational and personal lives.
backs, but they introduce the problem of degraded
visual acuity, and the occasional patient reports
noticeable unes when looking through the prisms, Heterophoria
The prognosis for improving existing visual effi-
ciency skills in heterophoria s almost always
good, provided that there is adequate coopera-
tion and motivation on the part of the patient. If a
patient demonstrates outstanding motivation, that
patient can be told the prognosis is "excellent."
Such superlatives, however, should be used spar-
ingly. Heterophoria therapy is usually effective in
Chapter 6 199

abating associated signs and symptoms (Table


6-5). In the sensory realm, stereopsis might be TABLE 6-5. Signs and Symptoms FrequentJy
improved by means of visin training, lenses, or Occurrng n Heterophoria
prisms. In the motor realm, visin training may
help to increase fusional vergence ranges, which
Blurring of visin at farpoint Bfurrng of visin at
may be necessary in cases of fixation disparity. nearpoint Frownng or squinting of eyelids Excessive
Also, the use of prisms s applicable in cases of blinking when reading Covering or closing one eye
heterophoria, especially for patients with fixation during reading Confusing, omitting, or repeating words
disparity. when reading Sustaining nearpoint work with diffculty
Of the four generally recognized types of ver- Reading at a very slow rate Losing place when reading
gencetonic, accommodative, fusional, and prox- a book Burnng, aching, tching, or tearing of eyes, or
imalmost authorities believe tonic convergence photo-phobia
is the least changeable as a result of training.
Although there is some dispute over whether the
basic deviation can be changed by training, we For all patients, whether strabismic, hetero-
believe t remains approximately the same in the phoric, or orthophoric, testing for and diagnosing
long run. On immediate testing, however, there deficiencies of other visual skills (e.g., saccades,
may appear to be a post-training difference. How- pursuits, fixations, accommodation [sufficiency,
ever, when there is prolonged occiusion (e.g., sev- facility, stamina], and the status of fixation dispar-
eral hours), tonic convergence is usually found to ity) should be undertaken. The prognosis s gener-
be the same as t was before training. ally good for resolving problems in these reas by
As regards accommodative vergence, Manas,15 means of visin therapy.
by measuring the AC/A ratio, reported an mercase
with convergence training. Flom 16 questioned
the results of Manus, but in his own study, he MODES OF VISION THERAPY
found a similar increase. However, after approx-
imately 1 year, Flom found that the AC/A ratio Before a prognostic statement for either a func-
appeared to have decreased and approximated the tional or cosmetic cure can be considered com-
original vales. plete, the doctor must take into account the type
Numerous researchers have reported on the of therapy that must be administered to effect
trainability of fusional vergences. Costenbader17 the desired results. An overview of approaches
stated, "In general, the treatment of strabismus to visin therapy n cases of binocular anomalies
ncludes . . . improving fusin and the fusional s presented in this section. (Figure 6-3 summa-
vergences." Jones18 wrote, "In regard to motor rizes the modes and classification of visin ther-
fusin, it is the aim of orthoptic treatment . . . to apy.) In cases that carry a poor prognosis, the
ncrease them [fusional vergence ranges] suffi- doctor may recommend no treatment rather than
ciently." Griffin 19 summarized research proving visin therapy. This is sometimes the wisest
the efficacy of fusional (disparity) vergence train- option for certain patients. (See the case exam-
ing. In general, the prognosis for ncreasing ples later in this chapter.)
fusional vergence is good. The fusional vergence
that is easiest to treat by training s fusional con- Lenses
vergence, followed by fusional divergence. The first consideraron in the treatment of any bin-
Improving vertical fusional vergence by means of ocular visin condition is full correction of the
training s the next most difficult. In most cases, refractive error, as a defocused or distorted image
torsional fusional vergence is the most difficult to to either eye (or possibly to both eyes) is an obsta-
train successfully. cle to fusin. Lens additions (plus and minus) are
Excessive proximal convergence usually dimin- also used in the treatment of certain types of stra-
shes on familiarity with the testing environment bismus and heterophoria. Lens therapy is dis-
that originally produced the ncreased vergence. cussed n PartTwo of this book.
This has occupational importance (e.g., controlling
the tendency to overconverge the eyes when using
binocular instruments such as a biomicroscope).
200 Chapter 6

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

FIGURE 6-3Classification of visin therapy.

Prisms cosmetic unilateral strabismus is present, small


For more than 100 years, prisms have been used to amounts of reverse prism can often mask its appear-
compnsate the angle of strabismus. The primary lim- ance. Reverse prisms have also been used to break
itation has been the amount that can be effectively the adaptations of suppression, ARC, and eccentric
incorporated nto spectacle lenses. Prisms often fixation in selected cases.
become impractical due to their weight and distor- The use of compensating (relieving) prisms n
tion when more than 10A per lens is required. With cases of heterophoria has continued to grow in
the advent of Fresnel prisms, the limit has increased clinical practice, especially n cases of excessive
to 30A per lens which is usually sufficient as most heterophoria. If the angle of deviation does not
strabismic deviations measure less than 60An mag- adapt to the prism power (i.e., phoria increasing in
nitude. However, Fresnel prisms appear, at best, to be magnitude), asthenopic symptoms usually are
only a temporary solution because of optical distor- resolved or diminished. However, some patients
tion, reduced visual acuity, and loss of contrast. Fur- show prism adaptation, which suggests that this is
thermore, compensating prisms do not help (but not a viable therapeutic option.
hinder) the cosmetic aspect of strabismus, which
exacrbales this major concern of most strabismic Occiusion
patients. The use of reverse (inverse) prisms, however, Occiusion (i.e., opaque patches or attenuating fil-
may be attempted to improve the cosmetic appear- ters) s used to treat amblyopia (Chapter 10), ARC
ance n some strabismic cases. When a borderline (Chapter 11), suppression (Chapter 12), and com-
Chapter 6 201

tant and noncomitant strabismus (Chapters 13-15).


Prognostic considerations regarding occlusion are
discussed n the aforementioned chapters.

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

Oculus dexter (OD): plano, 20/400 (6/120) Case 2


Oculus sinister (OS): plano, 20/20 (6/6) The patient is 9 years od with a history of constant
The deviation is a noncomitant, constant, unilat- esotropa since the age of 1 year. No prevous
eral esotropa of the right eye of 15A at far and near, treatment has been given. The patient does not
with a normal AC/A ratio (6/1), and good cosmesis. report diplopa. Refracton is
The associated conditions include lack of any fusin;
OD: +2.50 - 0.50 x 180, 20/40 (6/12)
deep amblyopia; nasal, unsteady, parafoveal, eccen-
OS: plano, 20/20 (6/6)
tric fixation; complete lack of correspondence; poor
accommodative facility in the amblyopic eye; no Vision at near was commensurate with that at far.
motor fusin; and slightly noticeable facial asym- The deviation s a comitant, constant, alternat-
metries. Muscle testing indicates a complete pare- ing, esotropa, with the left eye being preferred.
sis of the right lateral rectus. Cosmesis is not a The devation s 45A at far and 35A at near, with a
concern to the patient or parents. low AC/A ratio (2/1). Cosmesis is poor. The associ-
The basic esotropa of this 10-year-old patent s ated conditions include deep peripheral suppres-
congental. The prognosis for a functional cure by sion; shallow amblyopia with unsteady central
any or all means of therapy s poor. Flom's prognosis fixation; probable harmonious ARC; horror fusio-
chart for a functional cure of the strabismus would nis; and no motor fusin or stereopsis.
indcate 0% chance of success (see Table 6-4). This case can be described as divergence insuffi-
It is also probable that the prognosis is poor for ciency esotropa because of the larger deviation at
any signifcant change in the status of the amblyo- far. The prognosis for a functional cure by any or
pia, because the devation has probably been all means of therapy is poor. The Flom prognosis
unilateral since brth; therefore, t can be specu- chart would indcate only a 10% chance for suc-
lated that the reduced visual acuity is due to cess (see Table 6-4). However, the prognosis for a
amblyopia of arrest. The ultmate dfferental diag- parta! cure s poor to fair, meaning that the large
nosis would be made by treating the condition to manifest deviaton could be converted into a
find out whether there is any improvement. If smaller devaton by means of surgery. This implies
there is enhancement of visual acuity, the amount that peripheral fusin might be developed or re-
of improvement represents that portion of visual educated, thereby helping the patent to hold the
loss due to amblyopia of extinction. If there is no eyes relatively straight. The patent would techni-
mprovement, the presence of amblyopia of arrest cally be strabismc but, f motor ranges could be
is confirmed, assuming any organic cause of developed, the patient could function with at least
reduced visual acuity has been ruled out. Predic- some degree of binocularty. This would be a
tive testing such as nterferometry and visually monofixation pattern. With a history of no previ-
evoked potentials could also be recommended. ous treatment and a duration of 8 years of constant
No treatment for the strabismus s recommended esotropa, there is little hope for anything beyond
n this case if the cosmesis is acceptable to the this expectation.
patient. Because the deviation s not large, the The shallow amblyopa s probably due to the ani-
appearance of the eyes is fairly good in the primary sometropia rather than the strabismus, as the devia-
gaze; however, the esotropa may become notice- tion s alternating and not unilateral. The prognosis
able on rght gaze because of the right lateral rec- for cosmetic cure by means of extraocular muscle
tus paresis. Cosmesis s acceptable otherwise. surgery s far to good. Prsm adaptation testing
Direct total occlusion should be recommended would be useful in ths case to predetermine whether
except when the patient cannot see well enough the angle of devation would be stable after the oper-
in school with the amblyopic eye. Occlusion ation. The patient should be advised that several
should continu for 1 or 2 months to determine appontments are needed for further evaluation and
whether there s any improvement. If visual acuity that visin training will be tried on a short-term basis,
mproves in the right eye, pleoptics to treat the approximately 5 weekly visits, to determine whether
eccentric fixation may be advised. If there is no there s any improvement in visual acuity. Correcting
change in visual acuity after that, further visin lenses should be worn during this time, along with
therapy is not indicated. The patient would then constant patching of the left eye in an attempt to
be advised to have a routine follow-up examina- improve the acuity of the right eye. After lenses and
tion in 1 year. visin training have achieved the mximum results,
208 Chapter 6

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

advised of the need for spectacles, occlusion ther- Case 8


apy, and approximately 30 weekly office appoint- The patient is 8 years od with a history of exotropia
ments along with ntensive home visin training. since the age of 3 years. The onset was intermittent,
Surgery should be recommended only f it is abso- and the condition has been so ever since. An exam-
lutely required for functional results. ination was performed at age 4 years. No significant
refractive error was found, and lenses were not pre-
Fair to Good Prognosis scribed. There has been no other examination since
Case 7 that time. The present refractive error is
The patient s 6 years od and has had an exotropic OD: plano, 20/20 (6/6) OS:
deviation of the left eye since the age of 4 years. plano, 20/20 (6/6)
Since then, the strabismus has been intermittent.
Vision at near was commensurate with that at far.
No previous treatment has been given. The present
The deviation is a comitant, ntermittent (25% of
refraction s
the time at far and 95% at near), unilateral exotro-
OD: plano, 20/20 (6/6) OS: pia of the right eye of 15A at far and 25A at near.
plano, 20/30 (6/9) Cosmesis is fair. The associated conditions include
moderately deep peripheral suppression when the
Vision at near was commensurate with that at far.
deviation is manifest; covariation between harmo-
The deviation s a comitant, intermittent, unilat-
nious ARC and NRC; a limited motor fusin range;
eral exotropia of the left eye of 20A at far and 5A at
and poor stereopsis.
near, with a high AC/A ratio (12/1) and poor cosme-
This patient has convergence insufficiency exotro-
sis. The appearance of the strabismus s very notice-
pia. The prognosis for a functional cure by means of
able because of the intermittence and a positive
visin training s fair to good. The Flom prognosis
angle kappa (+1.5 mm). The exotropia s estimated
chart would indcate an 80% chance for success (see
to be present 90% of the time at far and 10% of the
Table 6-4). Other supplemental testing, such as the
time at near. Associated conditions include deep
prolonged occluson test, could help to make the
peripheral suppression when the deviation s mani-
prognosis more decisve. It would also be helpful to
fest; shallow amblyopia with unsteady central fixa-
know the patient's stereoacuity, f that can be elicited
tion; and covariation between harmonious ARC and
at times when the patient s fusing.
NRC. An exo fixation disparity is detected when
Surgery is probably not called for in this case. All
there is bifixation at the nearpoint with an associated
that may be required to cure this patient with conver-
exophoria of 4A. Motor fusin (disparity vergence)
gence insufficiency is visin training that emphasizes
ranges are very limited, being from 22-18A base-in
antisuppression and fusional convergence training.
at far and from 8A base-in to 1A base-out at near.
The patient should be advised to plan for 25
This case is a classic example of divergence
weekly visin therapy appointments and vigorous
excess exotropia. The prognosis for a functional
home training, with the remote possibility of extraoc-
cure by means of lenses and visin training s fair
ular muscle surgery.
to good. The Flom prognosis chart would indcate
a 70% chance for success (see Table 6-4). The
prognosis must be guarded because of the larger Case 9
deviation at farpoint and the intense and extensive The patient is 35 years od and is reporting nter-
suppression when the deviation is manifest. ARC s mittent diplopia of sudden onset after trauma to
not a significantly adverse factor with which to be the head in an automobile accident 3 weeks ago.
concerned, because normal correspondence pre- This resulted in a mild paresis of the left superior
dominates while there is fusin. oblique muscle. The refractive history s unre-
Monocular visin therapy should be done n con- markable with the exception of a small myopic
junction with binocular sensory and motor fusin refractive error. The present prescription being
training in order to elimnate the amblyopa as worn is
quckly as possible. The patient should be advised
OD: -1.00 DS, 20/20 (6/6)
that spectacles, probably bifocals (see Chapter 14 for
OS:-1.0005,20/20(6/6)
explanation), and approximately 25 weekly office
visits and diligent home training are recommended. Vision at near was commensurate with that at far.
Chapter 6 211

The deviation s a noncomitant, intermittent, The deviation s a comitant, intermittent (10% of


unilateral hypertropia of the left eye of 6A at far and the time at far and 90% at near), unilateral esotro-
near. Also, there are deviations of 1 -degree excyclo pa of the right eye of 6A at far and 16A at near.
deviation, 4A of eso at far, and 7A at near. Cosmesis Cosmess is good. There s NRC. Associated condi-
is good in the primary position and on levoversion, tions include shallow central suppression; eso fixa-
but the hyper deviation s quite noticeable on dex- tion disparity (associated esophoria of 5A at far, but
troversion. The frequency of the manifest deviation nearpoint findings could not be obtained); and a
is approximately 50% of the time in the primary fair motor fusin range. Stereoacuity with con-
position and 100% on dextroversion. There s a toured targets was 120 seconds of are at far and 60
vertical fixation disparity, and the associated pho- seconds of are at near when +2.00-D addition
ria is a 4A left hyperphoria that is measurable only lenses were worn.
when the patient is fusing. This patient has an accommodative esotropa of
Additional information (e.g., stereoacuity and the high AC/A type. The prognosis for a functional
motor fusin ranges) would be helpful before the cure by means of lenses (bifocals) and visin train-
final prognosis s made. Assuming these additional ing s good. According to the Flom chart, the prog-
test results are relatively normal, the prognosis for nosis for functional cure would be 80% (see Table
this adult patient is fair to good for a functional 6-4). This s a classic case of convergence excess
cure by any means of therapy. There s a good beng caused by a high AC/A rato. The far devia-
chance of spontaneous remission of the superior tion may be partally alleviated by ncorporating
oblique paresis with the passing of time, and so base-out prism (less than 6A) n the patient's specta-
approximately 6 months should be allowed to cles. This together with bifocal additions will par-
determine whether the paresis will resolve. The tially alleviate the deviation at near.
Flom chart is not applicable n this case, but we The prognosis must be sghtly guarded because of
believe the overall prognosis s fair to good. the possible unacceptability of the spectacles by this
Management of the noncomitancy should 7-year-oId child. Otherwise, the prognosis is theoreti-
emphasize the prevention of extraocular muscle cally good. As in other cases, treatment depends on
contractures (see Chapter 15). The patient should good patient motivation and cooperation. These fac-
be advised to make follow-up appointments as tors must always be taken into account.
necessary for evaluation and training nvolving The patient should be advised to have five
occlusion, prisms, and fusional vergence improve- weekly office appointments for visin therapy after
ment. Communication with other specialists, par- the bifocal spectacles have been dispensed. The
ticularly the neurologist, should be maintained. patient will be taught to accept and properly use
The patient should be advised of the eventual pos- the spectacles. Some antisuppression training and
sibility of extraocular muscle surgery, although the a great deal of fusional vergence training is
necessity for this seems unlikely. required. Fortunately, much of this can be done at
home, assuming the patient and parents are moti-
vated and cooperative.
Good Prognosis
Case 10 Case 11
The patient s 7 years od with a history of The patient is 8 years od and has a history of inter-
esotropa since the age of 4 years. The onset was mittent exotropia at near that was first noticed at
intermittent, and the condition has remained so. age 6 years. The frequency of the deviation has
The patient was examined at age 5, at which increased somewhat since that time. No previous
time a small amount of hyperopia was found n treatment has been given. Refraction is
each eye, but no lens prescription was given.
OD: -1.00 DS, 20/20 (6/6)
Diplopia s noticed occasionally during near-
OS: -0.25 DS, 20/20 (6/6)
point tasks. Cycloplegic and manifest refraction
results are Vision at near was commensurate with that at far.
The deviation s a comitant, intermittent (5% of
OD: plano, 20/20 (6/6)
the time at far and 40% at near), unilateral exotro-
OS: plano, 20/20 (6/6)
pia of the right eye of 8A at far and 20A at near. The
Vision at near was commensurate with that at far. AC/A ratio is very low (1.2/1.0). Cosmesis s good
212 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
to the Flom prognosis chart (seeTable 6-4). This case
1. Flom MC. The prognosis n strabismus. Am J Optom Arch
of convergence insufficiency exotropia should be Am Acad Optom. 1958;35:509-514.
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pic anisometropia. Also, fusional vergence ranges Anomalies. In: Principies and Practice of Pediatric
can most probably be expanded by means of visin Optometry. Rosenbloom AA, Morgan MW, eds. Philadel-
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3. Manley DR. Symposium on Horizontal Ocular Devia-
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Wkly. 1970;61:28-29.
Case 2 5. Ludlam WM. Orthoptic treatment of strabismus. Am J
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nosis. New York: Intercontinental Medical Book Corp;
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OS: plano, 20/20 (6/6) 8. Wybar K. The Use of Prisms n Pre-Operative and Post-
Operative Treatment. In: First Congress of the Interna
Vision at near was commensurate with that at far. tional Strabismological Association. Fells P, ed. St. Louis:
The deviation is a comitant exophoria of 5 A at Mosby; 1971:245.
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on Strabismus, Transaction of the New Orleans Acad-
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emy of Ophthalmology. St. Louis: C.V. Mosby;
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2A). Noncontoured (random dot) stereoacuity was Noncentral Fixation. In: Orthoptics. Mein J, ed. Amster-
20 seconds of are at near. The only other abnormal dam: Excerpta Medica; 1972:369.
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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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heterophoria and not strabismus, the patient does Am] Optom. 1958;35:428-437.
not meet the criteria of Flom as being functionally 16. Flom MC. On the relationship between accommodation
cured because of the blurring of visin and discom- and accommodative convergence. Am J Optom. 1960;
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.
patient is cured, the patient then is treated as in het- 18. Jones BA. Orthoptic handling of fusional vergences. Am
erophoria therapy to effect a cure of any deficient OrthopJ. 1965;15:21-29.
binocular visual skills and, it is hoped, to enhance 19. Griffin JR. Efficacy of visin therapy for nonstrabismic ver
gence anomalies. Optom Vis Sci. 1987;64:411-414.
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Chapter 6 213

20. Hugonnier R, Hugonnier S, Troutman S. Strabismus, Het- baum AL, Santiago AP, eds. Philadelphia: Saunders;
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1969:595-664. 38. Helveston EM. Surgical Management of Strabismus: An
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Review of Orthoptics and Ocular Motility. St. Louis: 1993:305-333.
Mosby; 1972:202-238. 39. Abraham SV. The use of miotics in the treatment of con-
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Motility Disorders, 2nd ed. Oxford: Blackwell Scientific; 1949;32:233-240.
1991:166-195. 40. Gellman M. The use of miotics for the correction of
23. von Noorden GK, Campos EC. Binocular Vision and Ocu hypermetropia and accommodative esotropa. Am J
lar Motility: Theory and Management of Strabismus, 6th Optom. 1963;40:93-101.
ed. St. Louis: C.V. Mosby; 2002:566-631. 41. Bartlett JD, Jaanus SD. Ocular Pharmacology, 4th ed. Bos
24. Dale RT. Fundamentis of Ocular Motility and Strabis ton: Butterworth-Heinemann; 2001:825-826.
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
nosis. In: Symptoms on Strabismus, Transaction of the VisSci. 1973;2:92 4-929.
New Orleans Academy of Ophthalmology. St. Louis: C.V. 43. McNeer KW, Magoon EH, Scott AB. Chemodenervation
Mosby; 1971:34-92. Therapy: Technque and Indcations. In: Clinical Strabis
26. Aust W, Welge-Lussen L. Pre-operative and post-operative mus Management. Rosenbaum AL, Santiago AP, eds. Phil
changes in the angle of squint following long-term, pre- adelphia: Saunders; 1999:424.
operative, prismatic compensation. In: First Congress of 44. Garnham L, Lawson JM, O'Neill D, Lee JP. Botulinum
the International Strabismological Association. Fells P, ed. toxin in fourth nerve palsies. Aust NZ J Ophthalmol.
St. Louis: Mosby; 1971:217. 1997;25:31-35.
27. Alpern MB, Hofstetter HW. The effect of prism on esotro 45. Ohba M, Nakgawa OM. Treatment of paralytc esotropa
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
Library, Southern California College of Optometry, Fuller- Center. Singapore Med. 1999;40:405^09.
ton, Calif., 1972. 47. Dawson EL, Marshman WE, Lee JP. Role of botulinum
29. Crter DB. Effects of prolongad wearing of prism. Am J toxin A in surgically overcorrected exotropia. J AAPOS.
Optom. 1963;40:265-272. 1999;3:269-271.
30. Jampoisky A. Adjustable Strabismus Surgical Procedures. 48. Lawson JM, Kousoulides L, Lee JP. Long-term results of
In: Symptoms on Strabismus, Transaction of the New botulinum toxin in consecutive and secondary exotropia:
Orleans Academy of Ophthalmology. St. Louis: C.V. outcome in patients nitially treated with botulinum toxin.
Mosby; 1978:320-328. J AAPOS. 1998;2:195-200.
31. Wygnanski-Jaffe T, Wysanbeek Y, Bessler E, Spierer A. 49. Lennerstrand G, Nordbo OA, Tian S, et al. Treatment of
Strabismus surgery using the adjustable suture technique. Strabismus and nystagmus with botulinum toxin type A.
J Pediatr Ophthalmol Strabismus. 1999;36:184-188. An evaluation of effects and complications. Acta Oph
32. Chan TK, Rosenbaum AL, Hall L. The results of adjustable thalmol Scand. 1998:76:27-37.
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1999;13:567-570. Botox. J Pediatr Ophthalmol Strabismus. 1995;32:306-308.
33. Bacal DA, Hertle RW, Maguire MG. Correlation of post- 51. Rayner SA, Hollick EJ, Lee JP. Botulinum toxin in child-
operative extraocular muscle suture adjustment with its hood Strabismus. Strabismus. 1999;7:103-111.
immediate effect on the strabismic deviation. Binocul Vis 52. Robert PY, Jeaneau-Bellego E, Bertin P, Adenis JP. Valu of
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:
rectus muscle recession surgery: a follow-up study. Arch 508-514.
Ophthalmol. 1977;95:817. 53. Ruiz MF, Moreno M, Snchez-Garrido CM, Rodrguez
35. Hwang JM, Chang BL. Combined effect of Interceed and JM. Botulnum treatment of infantile esotropa with
5-fluorouracil on delayed adjustable Strabismus surgery. abduction nystagmus. / Pediatr Ophthalmol Strabismus.
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

Accommodative Esotropa 215 Vision Training 223 Surgery


Refractive Accommodative 223 Primary Comitant Esotropa
Esotropa 216 Characteristics 224
216 Management 216 Optical Characteristics 224
Treatment 216 Other Approaches Management 225 Primary
217 Accommodative Esotropa with Comitant Exotropia 225
a Characteristics 225
High Accommodative-Convergenee/ Management 227 A
Accommodation Ratio 217 and V Patterns 227
Characteristics 217 Management 218 Characteristics 228
Optical Treatment 218 Vision Training Management 229
218 Miotics 219 Surgery 220 Infantile Microtropia 229
Esotropa 220 Characteristics 220 Clnical Characteristics 229
Management 222 Optical Treatment Management 231
222 Cyclovertical Deviations 232
Comitant Vertical Deviations 232
Dissociated Vertical Deviations 233
Sensory Strabismus 233 Consecutive
Strabismus 234

Several types of Strabismus occur in young patients ACCOMMODATIVE ESOTROPA


during their early formative years. If the deviation
s caused primarily by genetic factors or develop- The two general types of accommodative esotro-
mental anomalies n oculomotor control, t can pa that often require different optical treatment
be described as a developmental Strabismus. This approaches are refractivo (normal accommodative-
chapter discusses the clinical Characteristics and convergence/accommodation [AC/A] ratio) and
management principies of common developmen- nonrefractive (hgh AC/A ratio). There exsts an
tal deviations that are usually comitant. Paralytic accommodative component to most eso deviations
Strabismus and oculomotor restrictions, although that occurs during the early developmental years; in
they often occur during childhood or may be con- that sense, most cases of esotropa can be consdered
genital, are discussed n Chapter 8. partially accommodative in etiology. Our dscussion
216 Chapter 7

TABLE 7-1. Characterstics of Accommodative Esotropa

Refractiva Esotropa Hgh AC/A Esotropa

Mechanism Uncorrected hyperopia High AC/A ratio Limited


Limited divergente divergence Most often at
Onset Most often at 2-3 yrs od 2-3 yrs od +2.25 DS
Ref ractive error +4.75 DS Often constant at near distances
Constancy Usually ntermttent Usually normal retina! correspondence
Correspondence Usuaily normal retina! correspondente Rare High
Amblyopia Rare Fair with plus-addttion lenses and visin
AC/A rato Normal training
Prognosis Good wfth correction of hyperopia

AC/A = ommodative-convergenee/accommodation; DS = diopter sphere.

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

even after these measures have been applied, the


patient is unable to relax accommodation sufficiently
toachievethefull ametropic correction. Iftheaccom -
modative spasm perssts for weeks, power of the plus
lenses must be reduced accordingly.
Soft contact lenses have proven particularly use-
tul and acceptable to patients for alleviation of
4
accommodative esotropa. The optical properties
of contact lenses may be beneficial as compared
with spectacle lenses. Slightly less accommodation
is required to focus an mage at near using plus
contact lenses as compared with plus-lens specta-
cles, due to the difference in vrtex distance.
5
Grisham et al. found that contact lenses were
more effective than spectacle lenses in reducing
residual angles of eso deviation (either esophoria
or esotropa). Wearing of contact lenses also
resulted in better fusiona! control in cases of NRC.
For patients younger than 1 year, retinoscopy
should be repeated every 3 months, because refrac-
tive changes during infancy are frequent. New lenses
are indicated if there s a change of at least 1 D. Fol-
low-up examinations should be performed at least
every 6 months in these chldren from ages 1 to 5
years to ensure that the lens prescription is current
and fusiona! control of the deviation is maintained.
FIGURE 7-1Refractive accommodative esotropa without specta-
cle lens correction (a) and with lenses that fully correct the manifest
Other Approaches
deviation (b).

Vision training is useful in many cases of accom -


modative esotropa f the child can cooperate. In postsurgical cases of refractive esotropa, con-
Ratients who undergo visin training tend to main- secutive exotropia s a common fnding when lenses
tain a good result longer than do patients who do are eventually worn for the hyperopia. Surgery may
not receive visin training. If there s NRC, the be ndcated, however, n cases of partially accom-
goals of visin training are to elimnate any ambly- modatve esotropa in whch there remains a con-
opia, break suppression, and buld fusional dver- spicuous residual strabismus after ful I correction of
gence ranges with reflex control. (Refer to Chapter the refractive error. Surgery for any signficant asso-
13 for visin tranng techniques for eso devia- ciated hyper deviation or marked A-V pattern may
tions.) Often a patient who has completed visin also be necessary and approprate.
therapy can remove the lenses for brief perods,
such as for swmming or other sports, and still
mantan fusional control of the devaton. Accommodative Esotropa with a High
The use of motics or surgery n cases of refrac- Accommodative-Convergence/
tive accommodatve esotropa s strongly discour- Accommodation Ratio Characteristics
aged. Miotcs are only a temporary solution at best Accommodatve esotropa may occur even when
and are assocated wth many possible undesrable there is lttle or no hyperopia. This can be due to a
side effects. They should be tred only after com- hgh AC/A rato, n which there is an excessive
plete optcal treatment has faled to acheve align- amount of accommodatve convergence wth a rel-
ment and fusonal control. For example, some atvely small amount of accommodaton. In this
children initally refuse to wear the prescribed stuation, an esotropa may occur at near fixaton
lenses. Later, however, they may prefer the optical dstances when fusional divergence s insuffcient
treatment to daly instllaton of eye drops.
218 Chapter 7

Management
Optical Treatment

Because of the high AC/A ratio in this type of strabis-


mus, it s usually necessary to correct any manifest
hyperopia with lenses. Cycloplegic refraction should
be performed to reveal any latent hyperopia. In addi-
tion, the optimum bifocal lens power should be deter-
mined to promote fusin at the patient's nearpoint
working distance. This amount is, of course, deter-
mined under noncycloplegic testing conditions. Plus-
lens additions are used for the patient's preferred
working distance to determine empirically which
power will best align the eyes. In effect, this technique
uses the measured AC/A ratio (.e., lens gradient
method) to determine the optimum bifocal power.
When prescribing a bifocal lens for very young chil-
dren, t s important to fit the bifocal une high, at mid-
pupil, if the lens is to be used properly (Figure 7-2). For
FIGURE 7-2Proper segment height for a child with accommoda- older children and adults, the segment height can be
tive esotropa with a high accommodative-convergence/accommo- slightly lower. By age 8 years, the segment line can be
dation ratio. at the lower edge of the pupil. By teenage years, the
line can be atthe lower eyelid margin. For progressive
addition lenses, the fitting would be approximately 2
to compnsate for the excessive accommodative mm higher than a linear segment bifocal lens.
convergence. This type of accommodative strabis- For older children and adults, bifocal contact
mus, called high AC/A accommodative esotropa, lenses may be considered as an alternative to bifocal
s known also as convergence excess esotropa in spectacles n the high AC/A type of accommodative
the Duane-White classification system. The main esotropa. The added near power s useful n all fields
distinguishing feature of high AC/A accommoda- of gaze, unlike spectacle bifocals, and many patients
tive esotropa s that the magnitude of the devia- do not report dfficulty wth the slight decrease in
5
tion at near exceeds that at far distance. This stands contrast inherent n the bifocal contact lens design.
in contrast to refractive accommodative esotropa, One recent longitudinal study, however, indicated
in which the near and far deviations are approxi- that more than 40% of optically aligned accommo-
mately equal (i.e., a basic eso deviation). As in dative esotropes did not remain so over a 7-year
6
refractive accommodative esotropa, high AC/A period. This finding Ilstrales the importance of
accommodative esotropa is usually intermittent cise follow-up examinations and subsequent refrac-
with NRC. tive and visin training management of such patients.
High AC/A accommodative esotropa s rela- Another consideration that clinicians should
tively independent of refractve error. High hypero- keep n mind when a previously corrected accom-
pia is possible but rare. However, many patients modative esotropa deterirales at near is the pos-
have mild to modrate degrees of hyperopia. In sibility of a psychological etiology resulting n a
7
one series of patients with high AC/A accommoda- spasm of the near reflex triad. Such patients may
tive esotropa, the average refractive error was require palliatve therapy, such as a reading add,
1
+2.25 D, whch s approximately half the average and professional counseling.
amount of hyperopa found n refractive accom-
modative esotropa. There s, however, wide vari- Vision Training
ablty in refractive error, with some patents
presenting with emmetropia and even myopia. In After the optimum bifocal correction has been pre-
those cases of moderately high hyperopia n com- scrbed to promote alignment at far and near, visin
bination with a high AC/A, treatment must address training is recommended to build a reserve of
both causes of the deviation. fusiona! vergence function. Vision therapy should
Chapter 7 219

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

that developed within the frst 6 months of life (Figure


7-3). The term congenital, however, lterally means
10 "existng from birth" and does not adequately
In summarizmg his clinical mpressions, Raab
describe most of the esotropa cases occurring at an
spoke disparagingly of the results of miotic manage-
early age that have many of the same clinical charac-
ment of accommodative esotropa. He has found
teristics. Therefore, the term infantile esotropa s pref-
that compliance with miotics has been nadequate
erable and connotes a period of onset from brth to 6
n patients n whom compliance with bifocal lenses 14
months. Nixon et al. reported that only a fracton of
has faltered. This finding suggests that the real prob- cases of nfantile esotropa are reliably observed to
lem is one of parent-child conflict over therapy and orignate at birth. Furthermore, the eyes of a neonate
that this issue needs to be resolved rather than sub- rarely are aligned exactly and consistently during the
stitu ng one therapy for another. first week of life; the deviation usually is variable,
sometimes algned and other times convergent or
Surgery
divergent. Normally alignment and coordinated ocu-
lomotor control s not rudimentarily established until
An operation may be indicated if the AC/A ratio is 14 15
the age of 3 months. - Nevertheless, the specifc
extremely high (e.g., 10A/1 D or higher) or if the devi-
age of onset n constant esotropa s fundamentally
ation at near is not adequately control led by optical
mportant in establishing the prognosis for treatment
means or visin training. If the deviation occurs nterin
when the patient is first examned months or years
ittently and infrequently at near, the operation
later. The more time that normal binocular visin has
should be deferred until age 5 or 6 years, at which
had to develop prior to a constant manifest deviation,
time the patient is usually able to cooperate with pre-
the better s the prognosis for cure of the strabismus.
operative and postoperative visin training. The con-
The term infantile esotropa s somewhat ambigu-
ventional surgical procedure is a recession of both
ous n that the etiology of the strabismus, often
medial rectus muscles (e.g., 5 mm, each eye),
innervational, seems to be the same as that n PCE.
because this operation reduces the deviation more at 16
von Noorden suggested that the primary etiology
near than at far.11 Semmlow et al.12 reported good of nfantile esotropa s either delayed development
long-lasting reductions in the AC/A ratio of 21 of fusonal vergence or a primary defect of fusonal
patients having this surgical procedure. In cases of vergence. However, associated clnical features
very large esotropic angles at near (e.g., more than (e.g., dissocated vertical deviation, inferior oblique
45A), other surgical procedures may also be required overacton, and latent nystagmus) tend to occur n
for adequate reduction of the eso deviation. If the nfantile esotropa but not n esotropa of later onset.
patient has fairly good fusiona! abilities preopera-
tively, the surgical results are usually good. In some
surgical cases, however, the long-term result is a Characteristics
microtropia with only peripheral fusin.13 Approximately half of all nfantile esotropa patents
have hyperopic refractive errors of at least +2.00
17 18
D. Ingram and Barr, however, reported a study of
INFANTILE ESOTROPA 1-year-old infants from a general pediatric practice
In the past, the term congenital esotropa was applied in which only 11% of patients had hyperopia in this
to those cases of primary comitant esotropa (PCE) range. Although accommodation may be a factor in
the etiology of infantle esotropa, most nfantile
esotropa cases are not exclusively accommodative.
A
The angle of deviation s usually large (30 or more),
stable, comitant, and approximately the same mag-
nitude at all dstances (whch indcates a normal
AC/A ratio). Characteristics of nfantile esotropa are
usted inTable 7-2.
Clnicians frequently observe crossed fixation n
infantile esotropa. The child uses the right eye for tar-
gets n the left visual field and the left eye for objects
n the right field. This crossed fixaton behavior
accounts for an apparent lmitation of abduction of
Chapter 7 221

TABLE 7-2. Characteristics of Infantile Esotropa

Itechanism Innervational; familial ten-dency


(genetic)
Onset Birth-6 mos
Wefractive error In approximately 50%, <2 D of
hyperopia
ancy Usually constant angle, >30
A

nitancy Usually comftant


laterality Often either altemating or crossed f
ixation pattern
spondence Usually anomalous retinal cor-
respondente; in some cases,
lack of correspondente
Approximately 40% of cases
L ratio ams |-term Usually normal
prognosis Usuatty cosmetk concerns on\y
Poor if treated after age 2 yrs;
fair if treated before age 2 yrs
Overacting inferior oblique musdes,
|-term
dissociated vertical deviation, latent
asociattons
nystagmus

accommodative-convergence/accommodation.

each eye that s often observed. Testing ocular rota-


tions adequately in extreme fields of gaze is difficult
in infants, particularly if they have developed the
habit of crossed fixation. Repeat testing and observa-
tion may be needed to differentiate a true paresis from
an apparent abduction limitation resultingfrom habit-
ual crossed fixation. Observing abduction during the
doll's-head maneuver, left and right, may help one to
make the distinction between a lateral rectus paresis
and a pseudoparesis. The examiner holds the infant
directly in front and makes eye contact while rotating
the patient's head to the left and right. For example,
the examiner should look for abduction of the
patient's right eye as the head is rotated to the patient's
left. If the right eye is seen to abduct, pseudoparesis is
indicated. The unaffected, or less affected, eye should
be patched for a few days to determine whether
FIGURE 7-4Overacting inferior oblique muscle. a. Primary gaze.
abduction rapidly develops in the other eye. If it does, b. Right gaze with large overaction of the left inferior oblique muscle.
then pseudoparesis is confirmed. If, however, paresis c. Left gaze with smaller overaction of the right inferior oblique muscle.
is present, there will be little or no abduction.
Amblyopia often is associated with infantile esotro- likely become deep and unresponsive to subsequent
pa f the child habitual ly fixates with only one eye. therapy at ages 5-7 years or older.
Two large clinical surveys of children with infantile Vertical deviatons often are associated with
esotropa found amblyopia in 35% and 41% of the well-established infantle esotropa, but ther etiol-
samples, respectively.17-19 Established amblyopia in ogies are not well understood. One common con-
infancy, if not dentified and treated early, will most dition is overacton of one or both inferior oblique
muscles (Figure 7-4). The clinican may observe an
222 Chapter 7

FIGURE 7-5Dissociated vertical deviation as


seen on the altrnate cover test.

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

Although it is beneficial in establishing some


TABLE 7-3. Characterstcs of Prmary degree of binocularity, early alignment does not
Comitant Esotropa guarantee stability over the long term. Amblyopia,
secondary overactions of the oblique muscles, and
Mechanism accommodative esotropa can al I develop; there-
Innervationat; familial tendency
fore, vigilant subsequent examinations and man-
(possibiy genetie) 6 mos-6 yrs of
Qnset agement are necessary.26"29
age; can be rapid or
gradual Some hyperopia in most;
Botulinum njection into the medial recti is not
Refr active error wide vari- recommended in cases of infantile esotropa, for
ation, approxtmately 5% myopic several reasons: Frequent injections are needed
Constancy A
Usually constant angle, 2Q-7Q ; ini- under general anesthesa, transient vertical devia-
tial stage possibly ntermittent tions and ptosis are common complications, and
Comitancy Comitant horizontally; A or V pat- research has not demonstrated better results than
tern In rnany cases Usually with conventonal surgical techniques.16
Corresponden ce anomaloui retnal corre-
spondence if eariy onset and
normal retnal correspondence if PRMARY COMITANT ESOTROPA
late onset
Amblyopia PCE is also known as acquired nonaccommodatve
Approxirnately 30% of cases Usually normal;
AC/A ratio esotropa. Under the Duane-White classification
low in some cases Usually none
Symptoms system, there are three subclasses: basic eso devia-
Good f normal retina! correspondence;
Prognosis tion (BE), convergence excess (CE), and divergence
poor f anomalous retina!
correspondence insufficency (DI). This simplified classification is
based on the farpoint deviation in relation to the
AC/A " accommodattve-convergence/accommodation.
AC/A ratio. (See Chapter 3, as this classification
also applies to heterophoria.) The category of con-
vergence excess, or high AC/A esotropa, was dis-
the optimum age for an operation if free alternation
cussed earlier in this chapter; henee, only basic
has been established by occlusion and monocular
esotropa and DI esotropa are discussed here.
visin training techniques. Most authorities recom-
PCE occurs in early childhood, as does infantile
mend that surgery be performed before 2 years of
esotropa. The distinguishing feature of PCE, how-
age, although von Noorden16 reported some good
ever, s a later onset of the manifest devation, after
results in patients between ages 2 and 4 years.
6 months of age but usual ly before 6 years. Pre-
The recommended type of operation vares
sumably, a child wth PCE has had at least 6
from one authority to another. Dale 3 recom-
months of normal binocular development, during
mended recession-resection of the affected eye for
which the neurologic architecture that supports
deviations of less than 50A, even though this may
normal binocular visin has matured to a consid-
result in mild noncomitancy. For deviations of 50-
erable degree. Generally speaking, subsequent
70A, he recommended a three-muscle operation,
associated conditions such as suppression and
including recession-resection for one eye com-
amblyopia may be absent or only mild in severity.
bined with recession of the medial rectus of the
For example, ARC may or may not be present,
other eye. For deviations of 70-90A, four-muscle
depending largely on the age of onset of a constant
surgery (i.e., a recession-resection for each eye)
deviation. In contrast, it is almost always present in
may be necessary. von Noorden,16 on the other
cases of untreated infantile esotropa.
hand, recommended an initial binocular medial
rectus recession of varying amounts, depending
on the magnitude of the deviation, followed by, Characteristics
on another occasion, a resection of one or both The most important feature of PCE s patent age at
lateral recti if needed. If one or both inferior onset. (See Table 7-3 for characteristics of PCE.)
oblique muscles are found to be overacting, then The later the onset, the better s the prognosis.
von Noorden 16 combines myectomies of the Onset is often gradual, and the child may pass
affected muscles. through a period of intermittent esotropa before
the strabismus becomes constant. The size of the
Chapter 7 225

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

distribution of refractive error in exotropia resembles


TABLE7-4. Characterstics ofPrmary that in the general nonstrabismic population, and so
Comitant Exotropia myopia does not appear to play any special role in
the etiology of exotropia.38'39 Anisometropia, how-
ever, can hinder the control of exophoria and can be
Mechanism
Innervational; familial ten-
a precipitating factor.
dency; female-male ratio 2 The intermittent nature of exotropia causes
to1 some special problems. Constant strabismus of
Onset Birth-8 yrs; usually gradual developmental origin rarely results in subjective
Refractive error Wide variation; same as general
reports of asthenopia from patients, but patients
population with an intermittent deviation, even with deep
Constancy Approximately 80% intermit-tent; suppression when strabismic, frequently experi-
tendency to become constant over ence symptoms. Many individuis with intermit-
A
time; angle, 20~70 tent exotropia manifest their deviation mostly at
Comitant horizontally; A or V far and maintain fusin (with effort) at near.
Comitancy pattern in many cases Besides the common symptoms associated with
Usually normal retina! correspondente; excessive heterophoria at ner (i.e., tired eyes,
Correspondence f requent covar-iation of anomalous sleepiness, eyestrain, intermittent blurring of
retinal correspondence cases with the visin, reading difficulties, and headaches), the
intermittent deviation intermittent exotrope seems unusually predis-
Arrtblyopia Approximately 5% of cases
posed to photophobia. It is common to see an
AC/A ratio Usually normal or low; high in
individual with intermittent exotropia cise one
approximately 10% of cases eye or lapse into the deviation when stimulated
Symptoms Frequent photophobia, squinting
by bright light (e.g., as when walking from inside
(eyelids), or asthenopia a darkened theater into full sunlight). This "daz-
Long-term prognosis Good if intermittent; poor if zle" effect disrupts fusional control of the latent exo
constant with anomalous
deviation when fusional amplitudes are restricted,
retinal correspondence
whereas patients with adequate fusional ampli-
AC/A - accommodative-convergence/accommodation. tudes are not greatly affected in this manner.40 The
reason for this higher sensitivity of intermittent
exotropes as compared with other strabismics is
unknown.
tile exotropia, because of the common intermittent Intermittent exotropia also presents the exam-
nature of exotropia as compared with constant iner with some unique difficulties in establishing
esotropa. Also, the sequelae of the two conditions the correct diagnosis. The measured angles of devi-
differ. In these cases of early-onset constant exotro- ation at far and near are often not the true angles of
pia there is a high prevalence (67% in one study)37 deviation. The farpoint deviation often is less when
of other coexistent ocular and systemic conditions measured in a small, narrow examination room as
(e.g., ptosis, congenital nystagmus, prematurity, neu- compared with that measured in the open environ-
rologic and genetic diseases). ment. Burian and Smith41 reported significantly
We believe that exotropia is more likely to mani- larger exo deviations in 31 of 105 patients when
fest at a later age than is true of esotropa. Late-onset measured at 30 m (100 ft). For this reason, a ques-
intermittent exotropia often is associated with ill- tionable exotropic magnitude at far should be
ness, fatigue, and other precipitating factors such as remeasured while the patient is outdoors or looks
daydreaming, nattentiveness, and photophobic at a distant target through a window.
reactions. AIl these factors can disrupt fusional con- The measured deviation at near, where the exo-
trol of an exo deviation. Clinicians have traditionally tropic patient is usually fusing, can also be errone-
associated exotropia with myopia. The implication ous. Many exotropes fusing at near present with a
was that myopia played some part in the etiology of smaller measured nearpoint deviation than at far.
exotropia. However, most studies indcate that the Frequently, however, patching one eye for approxi-
mately 30 minutes results in an increased near
deviation that equals the farpoint magnitude. 42
Chapter 7 227

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.

FIGURE 7-6A and V patterns. a. A


pattern in esotropa of the right eye.
b. A pattern in exotropia of the right
eye. c. V pattern n esotropa of the
right eye. d. V pattern in exotropia
of the right eye. (RET = right esotro-
pa; RXT = right exotropia.)

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

TABLE7-5. Characteristics of Microtropia

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.

using the unilateral cover test to verify the deviation.


Perception of intersecting lines at the light suggests
and magnitude of eccentric fixation, because this
harmonious ARC (i.e., an angle S of zero in the pres-
can influence interpretation of the cover test (as to
ence of a strabismus). A gap in the line seen by the
magnitude of the strabismus).
deviating eye indicates central suppression. Harmo-
nious ARC and deep central suppression are seen
frequently in cases of microtropia. If there is any Management
amblyopia, visuoscopy (also referred to as visu- Microtropia in adults does not generally require
scopy) must be performed to check for the presence visin therapy. These patients are usually symptom-
232 Chapter 7

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
Consecutivo strabismus refers to an eye turn that REFERENCES
changes from one direction to the opposite direc-
1. Pollard ZF, Greenberg MF. Unusual presentations of
tion (e.g., when an exotropia becomes an esotropa accommodative esotropa. Trans Am Ophthalmol Soc.
postoperatively). There are very few spontaneous 2000;98:119-124.
cases reported that are independent of a specific 2. Parks MM. Abnormal accommodative convergence in
event, such as eye surgery or ocular trauma. Con- squint. Arch Ophthalmol. 1958;59:364-380.
3. Dale RT. Fundamentis of Ocular Motility and Strabis
secutive esotropa occurs almost exclusively after
mus. New York: Grue & Stratton; 1982:193,238.
surgical overcorrecton of an exotropia. 4. Calcutt C. Contact lenses in accommodative esotropa
A common surgical goal in management of therapy. BrOrthopJ. 1989;46:59-65.
exotropia is to leave the deviation slightly on the eso 5. Grisham JD, Gee C, Brott H, Burger D. Evaluation of Bifo
A cal Contact Lenses in the Control of Accommodative
side of alignment, approximately 10 eso, as there is
Esotropa. OD thesis, on file n the Library of the Univer-
a tendency for the eyes to diverge during the heal'mg
sity of California School of Optometry, Berkeley, 1992.
process. Occasionally, the overcorrection is exces- 6. Watanabe-Numata K, Hayasaka S, Watanabe K, et al.
sive, and a cosmetic esotropa is evident. When this Changes n deviation following correction of hyperopia in
occurs, patients often report postsurgical diplopia. children with fully refractive accommodative esotropa.
The reported prevalence of surgical overcorrections Ophthalmologica. 2000;214:309-311.
Chapter 7 235

7. Rutstein
20. IngRP.
25. von Spasm
Noorden
MR. The GK. of the
tim'mg near reflex mlmicking
A reassessment
of surgical deterio-
of infantile
alignment for esotropa.
congenital alignment restoring (subnormal) binocular visin guarantee
ratingAm)
accommodative
Ophthalmol.
(infantile) esotropa.esotropa. Optom
1988;105:1-10.
J Pediatr Vis Sc. Strabismus.
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77:344-346.
21. Lang J. Der kongenitale oder fruhkindliche Strabismus.
1999)36:61-68. 27. Havertape SA, Whitfll CR, Cruz OA. Early-onset accom
8. Ludwlg 1H, Parks J,MM,
26. Ophthalmologica.
Prieto-Diaz Getson PR,
1967;154:201
Prieto-Diaz Kammerman
I. Long -208. LA. Rate
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of22.
deterioration
Shon MA, in accommodative
Hahm KH, Han esotropa
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JM. to
Spontaneous 1999)36:69-73.
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the AC/A relationship.
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23. Taylor DM. Congenital Esotropa: Management and Progno esotropa. Strabismus. 2000)8:3-13.
9. Bartlett sis.JD,
NewJaanus SD, Piscella RG,
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24. London R, Drugs.
Griffin In:JR,
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10. Raab EL. Difficult Esotropa Entties: Principies of Man 378.
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11. Mein J, Trmble R. Diagnosis and Management of Ocular Mosby; 1986:536.
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1991:219-220,276-278. children: long term outcome regarding changes in binoc
12. Semmlow J, Putteman A, Vercher JL, et al. Surgical modi- ular alignment; a study of 956 cases. Binocul Vis Strabis
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33. Graham PA. Epidemiology of Strabismus. Br ) Ophthal-
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34. Krzystkowa K, Pajakowa J. The Sensorial State in Diver-
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41. Burlan HM, Smith DR. Comparative measurement of
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43. Pratt-Johnson JA, Tlllson G. Management of Strabismus
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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,
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47. Keiner EC. Spontaneous recovery in microstrabismus.
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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51. Sidikaro Y, von Noorden GK. Observation in sensory het- Orleans Academy of Ophthalmology. St. Louis: C.V.
erotropia. J Pediatr Ophthalmol Strabismus. 1982;19:12-19. Mosby; 1971:255.
Chapters / Other Oculomotor Disorders

Nurogenic Palsies 237 Orbital Anomalies 247


General Considerations 237 Internuclear and Supranuclear
Sixth Cranial Nerve Disorders 248
(Abducens) Palsy 239 Mbius Internuclear Ophthalmoplegia 248
(Moebius) Syndrome 239 Fourth Supranuclear Horizontal Caite Palsy
Cranial Nerve 249
(Trochlear) Palsy 239 Frontal Eye-Field Lesions 249
Third Cranial Nerve Occipital and Parietal
(Oculomotor) Palsy 240 Cortical Lesions 250
Myogenic Palsies 242 Brainstem Lesions 250
Myasthenia Gravis 242 Supranuclear Vertical Gaze Palsy 250
Dysthyroid Eye Disease 243 Parinaud's Syndrome 250
Chronic Progressive Progressive Supranuclear Palsy 251
Externa! Ophthalmoplegia 244 Parkinson's Disease 251 Nystagmus
Mechanical Restrictions o Ocular 252 Physiologic Nystagmus 252
Movement 245 Duane Retraction Voluntary Nystagmus 253 Congenital
Syndrome 245 Brown (Superior Nystagmus 253 Nystagmus Blockage
Oblique Syndrome 255 Latent Nystagmus 259
Tendn Sheath) Syndrome 246 Rare f ypes of Nystagmus 259
Fibrosis of the
Extraocular Muscles 247
Adherence Syndromes 247

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

Nerve VI Nerve IV Nerve III


Paretic Developmental
Causes
Strabismus Strabismus
Vascular Head trauma 18 19 21
Mode Of onset Usually sudden Usually gradual
Other known causes 17 32 15
or shortly
Tumors Aneurysm 18 8 15
after birth
Unknown causes 15 4 12
Age of onset Any age Between birth
4 2 14
Source: Modfied from JA and approxi-
Rush, UR Younge. Paralysis 27 36 23
mately age 6
of cranial nerves Hl, IV, and VI: causes and prognosis in
yrs
1,000 cases, Arch Qphthalmol, 1S81;99;76~79.
Diplopia Common Uncommon
Cornitancy Noncomitant Comitant; AorV
but can . pattern may
magnitude of strabismus when the unaffected eye s become be present
fixating; the secondary deviation is measured when comitant
the affected eye is fixating. In palsy of recent onset, with time
the secondary deviation is larger than the primary Head posture Usually Usually normal
deviation due to Hering's law of equal innervation abnormal
(discussed in Chapter 4). Amblyopa Rare, only if Common
Some of many possible causes of neurogenic early onset
palsies that result in strabismus are direct trauma to Correspondente Usualty normal Anomaious
the oculomotor nuclei or anywhere along the retina! corre- retina! corre-
course of the nerves, inflammations, myasthenia spondence spondence
common
gravis, mltiple sclerosis, brainstem or neurona!
Trauma neuro- Common Uncommon
tumors, and vascular disorders (e.g., aneurysms,
hypertension, atherosclerosis, bleeding from dia- fogc or sys-
temc disease
betes). Table 8-1 lists the frequency of etiologic
factors found by Rush and Younge. 1 The recent
onset of diplopia associated with noncomitant stra-
bismus at any age is a harbinger of active disease tion is easily differentiated from ocular torticollis
or injury. When this occurs, careful medical evalu- (caused by extraocular muscle palsy) by direct
ation and management are indicated. questioning of the patient or parents or testing for a
Patients with paretic strabismus often adopt an restricted range of head movement.
abnormal head posture, allowing them to maintain Recent diplopia, noncomitancy, and abnormal
fusin in the least affected field of gaze. The head is head posture are clinical features that distinguish
usually turned in the direction of the action field of acquired neurogenic palsy from developmental
the affected muscle. (See the discussion in Chapter comitant strabismus. Table 8-2 lists differential diag-
4.) Some patients with noncomitant neurogenic nostic features.
strabismus turn their heads in the opposite direction In paretic strabismus, it is important to distin-
to that expected, to increase the separation of the guish between a strabismus of recent origin, pos-
diplopic images so that one of the images may be sibly due to active pathology, and a benign
more easily suppressed or ignored. The same strat- noncomitant deviation of long duration. Clinical
egy may apply when some patients choose to fixate features more commonly associated with devia-
with the affected eye. The larger secondary devia- tions of recent origin are disturbing symptoms
tion has increased separation of the double images. (e.g., diplopia, nausea, vrtigo) and signs of
Congenital torticollis of the head can arise from abnormal head posture. These problems diminish
a structural deformity of the cervical vertebrae or or disappear when an eye is occluded. The later
the sternocleidomastoid muscle. This rare condi- the onset of the deviation, the more likely is a
report of diplopia.
Chapter 8 239

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

TABLE 8-3. Features of Oculomotor


(Third Nerve) Palsy

Exotropia due to involvement of the medial rectus,


Hypotropia due to involvement of the superior rectus
and inferior oblique.
Ptosls due to involvement of levator palpebrae.
Limited depression in abduction dye to involvement of
the inferior rectus.
Chin elevation in bilateral cases due to limited eleva-
tion and bilateral ptosis.
FIGURE 8-1Falling eye syndrome on left gaze, with paresis of the In some cases, labeted interna/ ophthalmoplegia,
superior oblique muscle of the fixating right eye. dilated fixed pupil of the affected eye(s). Other
cases ir which pupils are normal constitute externa/
ophbalmoplegia.
an underactive left superior oblique muscle, possi- Potential for several unusual effectsfrom aberrant
bly due to fourth nerve palsy. This is true even when regeneratton of the third cranial nerve in congenital
there is spread of comitancy. cases; jaw-wink ref lex, widening of eyelids on depres-
Patients with a fourth nerve palsy who choose to slonf and retraction of eye on attempted elevation.
fixate with the paretic eye demnstrate the falling
eye syndrome (more correctly, falling eye sign)
(Figure 8-1). When the patient fixates with the
affected eye, particularly in adduction, excessive medial rectus involvement; (2) hypotropia due to
innervation to the superior oblique muscle is nec- weakness of the superior rectus and inferior
essary to maintain fixation. Because of Hering's oblique muscles; (3) limited depression in abduc-
law, the yoked contralateral inferior rectus muscle tion due to inferior rectus weakness; (4) ptosis of
overacts, making the fixating eye appear to drop. the affected eye due to levator involvement; and
von Noorden et al.4 reported that 21% of trau- (5) possible dilation of a fixed pupil that does not
matic fourth nerve palsies in a large clinical series react to direct or consensual light stimulation. If
were bilateral. Other authors have reported even the fourth and sixth cranial nerves are uninvolved,
higher proportions of bilateral superior oblique the affected eye can be seen to abduct and intort
involvement.5 Severity of the paresis is often asym- with attempted depression (Table 8-3).
metric (one eye higher than the other), which can In cases of congenital third nerve palsy, there is
mask the bilateral nature of the condition. One dis- often aberrant regeneration of the nerve (the so-
tinguishing feature of bilateral involvement is finding called misdirection syndrome). Aberrant regeneration
a right hypertropia on left gaze and left hypertropia can consist of any of several features, all of which are
on right gaze. Another differential observation is a not necessarily present in a given patient6:
positive Bielschowsky head-tilt test on either right or 1. Pseudo-Graefe's sign: elevation of the upper
left tilt. For example, in a case of bilateral involve- eyelid on attempted down-gaze.
ment in which the patient presents with a right 2. Widening of the eyelids on adduction and
hypertropia in the primary position, the right hyper- narrowing on abduction.
tropia increases on right tilt; on left tilt, a left hyper- 3. A dilated, fixed pupil that does not react to
tropia manifests and increases. Another particularly direct or consensual light stimulation but that
sensitive diagnostic indication of bilateral trochlear does react slightly on convergence or on
palsy is the patient's observation of a double excyclo adduction. This has been called the pseudo-
tilt on a double Maddox rod test, Argyll Robertson pupil.
4. Retraction and adduction of the eye on
Third Cranial Nerve attempted up-gaze.
(Oculomotor) Palsy Aberrant regeneration is believed to be due to
Fortunately, congenital third nerve palsies are rare. axonal regrowth after a compression injury to the
The full syndrome includes (1) exotropia due to third nerve such as may occur during childbirth.
Chapter 8 241

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

diplopia often occur as the first signs of the condition,


TABLE 8-4. Features ofMyasthenia Gravis especially in adults. Ocular muscle nvolvement
eventually occurs in 90% of all myasthenia patients
and accounts for 75% of initial presentations.10 The
Possibly unilateral, but usually bilateral, ptoss that is deviation can mimic any oculomotor palsy: In this
variable and subject to fatigue; often first sign sense, t s the great pretender. The onset can happen
In 90% of cases, an oculomotor or strabismic deviation that at any age, but the disease usually becomes manifest
can mimc any single or combined muscle palsy,
" "
<v
great pretender11More frequent in women are
than in rnen, particularty at encountered, but the course of the condition in
ages 20-40 yrs Frequently affects the muscles of infants and children differs from that in adults, as
mastication, swallow- children exhibit a wider range of muscular involve-
in, and facial expression ment. The condition characteristically s variable,
marked by periods of exacerbation and remission.
Muscle function may change within minutes, hours,
or weeks.2
sion, explaining the neurologa basis for double
Myasthenia gravis is a skeletal muscle autoim-
elevator palsy s difficult. One possible explana-
mune disorder distinguished by a reduction of the
tion is that the initial deviation is an isolated palsy
available postsynaptic acetylcholine receptor sites
of the superior rectus and, with time and another
on the end plates at myoneural junctions. The anti-
lesin, there s involvement of the inferior oblique.
acetylcholine receptor antibody is present in
The features that distinguish the double elevator
approximately 80% of patients with the general-
palsy then become evident. A second explanation
ized disease and n approximately 50% of patients
suggests that the condition is not a palsy at all but
with myasthenia restricted to the ocular muscles.11
a restriction. In one study, three-fourths of the
Diagnosis of myasthenia gravis s based on demon-
patients who were believed to have double eleva-
stration of easy muscular fatigability and its rapid
tor palsy were found to have restriction in up-gaze
relief by systemic administration of an anticho-
on the forced duction test.8 Ziffer9 stated that the
linesterase agent such as edrophonium chloride
causes of up-gaze limitations, either monocular or
(Tensilon). A period of 5-10 minutes of closing the
binocular, include restriction secondary to supe-
eyes and resting also can temporarily restore func-
rior rectus paresis. It seems that an apparent con-
tions; this can be helpful for differential diagnosis
genital double elevator palsy can be caused by
from causes other than myasthenia gravis.
either a weakness or a restriction.
Treatment of myasthenia gravis falls within the pur-
If there truly is a weakness of elevation, the
view of a neurologist. Systemic anticholinesterase
Knapp procedure has proven to be effective in cor-
medications are given to treat the disease, but these
recting the hypotropia in the primary position. The
are rarely successful n completely controlling ptosis
medial and lateral rectus muscles of the paretic
and diplopia. In the purely ocular form of the disease,
eye are transposed to a position near the insertion
the administration of corticosteroids (e.g., pred-
of the superior rectus. If the elevation limitation s
nisone) on an alternate-day schedule has yielded
caused by a restriction, the surgical ntervention is
remarkably good results, approaching 90-100%.12
directed to releasing the restriction. The procedure
Due to the variable nature of the condition, prism
n such cases often nvolves a recession of the infe-
therapy s usually unsuccessful; the clinician often
rior rectus muscle and the inferior conjunctiva.
resorts to occluding one eye to relieve diplopia.
Although myasthenia gravis may mimic any single or
combined extraocular muscle palsy, including supra-
MYOGENIC PALSIES
nuclear and intranuclear ophthalmoplegia, eye mus-
Myasthenia Gravis cle surgery s generally not indicated unless the
Myasthenia gravis s a chronic, progressive disease deviation s stable over a long period of observation.
characterized by skeletal muscle weakness and A ptosis crutch fitted to a frame to elimnate the
fatigue and has a predilection for the muscles of mas- drooping lid or lids s occasionally beneficial. Fre-
tication, swallowing, facial expression and, particu- quent changes of Fresnel prism power can also be
larly, eyelid and ocular motility (Table 8-4). Ptosis and used to relieve diplopia. Thus, the ocular manifesta-
Chapter 8 243

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

steroids, diuretics, and immunologic med.cat.on. If


the patient's restrictive ocular motil.ty does not
TABLE 8-5. Classifcation of Ocular Changes n
respond sufficiently to systemic treatment ocular
Graves'Disease
muscle surgery usually is indicated. Similarly, if the
proptosis does not diminish, the patient may benef.t
Class from orbital decompression surgery.
Definitton Several therapeutic approaches to the manage-
ment of thyroid myopathy are available, but eacn
No signs or symptoms has its limitations. The extraocular muscles are
Ony signs (upper eyelid retraction and stare usuaUy \ni\amed, enlarged, and fibrotic \ate m the
w\th or w'rthout eyeVid lag or proptosteV, no disease. Most patients nave either simple hypotro-
symptoms pia or hypotropia combined with esotropa. Some
2 Soft-tissue invoivement (symptoms and signs) patients assume an e\evated chin posture because
3 Proptosis Ixtraocular muscle involvement of the restriction of motility in up-gaze. Each o
4 >sS 4ajp*L\c.: netvp r'crly6ir>*,r1t') these actors must be considered in the choice of
"' S Source: Modifled from DH Char. Thyroid Eye Disease,
3rd ed. Boston: Butterworth-Heinemann; 1997:46-56. therapeutic options. Initially, the patient's response
to medical treatment (antithyfoid medication, cor -
ticosteroids, and immunosuppressive drugs) is
IOP, as did 68% of patients without measurable evaluated. In cases of diplopia, prisms often are
proptosis n the primary position. There s computed found to be helpful unless the deviation exceeds
A
tomographic (CT) and ultrasound evidence of 10 . Because the deviation is usually noncomitant,
orbital involvement in almost all patients and clini- prism spectacles need to be designed for specific
cal evidence of bilateral eye involvement in 80 - uses at far and near. Presbyopic Graves' patients
24 25
90% of cases of hyperthyroidism. ' Even in cases in generally fare better with single-vision glasses than
which the condition appears unilateral, CT scans with bifocals. If the magnitude of the deviation is
26 variable, Fresnel prisms are practica! during this
usually show enlarged extraocular muscles.
14 phase, as the prism power can be changed easily.
Char proposed an abbreviated classifcatin sys-
Muscle surgery should not be considered until
tem for the progressive eye changes found in Graves'
the deviation is stable for 4-6 months. When mus-
disease (Table 8-5). The first two categories include
cle surgery is indicated, and it usually is after orbital
minimal eye involvement, whereas the others repre-
decompression, it is advisable for the surgeon to use
sent more serious eye findings. Soft-tissue involve-
adjustable sutures along with a large recession of
ment, class 2, refers to symptoms of excessive
the restricted muscle. The adjustable sutures give
lacrimation, sandy sensation, retrobulbar discomfort,
the surgeon the opportunity to fine-tune the residual
and photophobia, but not diplopia. There can be
deviation the day after the operation. A single mus-
injection of the conjunctiva and eyelid edema. Cor-
cle operation is reportedly successful in correcting
neal involvement, class 5, refers to varying degrees of 27 28
diplopia in 50-65% of patients. ' Single binocular
exposure keratitis due to the proptosis and lagoph- visin over a wide range of gaze is, however, an
thalmos. Loss of sight, class 6, usually is caused by unrealistic expectation in most cases of Graves'
compression of the optic nerve at the apex of the ophthalmopathy, but the combination of surgery
orbit by the enlarged extraocular muscles. and prisms usually eliminates diplopia in the pri-
Almost 90% of patients who develop the eye sign mary position and at the reading angle. Eyelid sur-
of Graves' disease undergo spontaneous remission gery for long-standing lid retraction or other lid
of most signs and symptoms within 3 years of sys- abnormalities should be undertaken as the last step
14
temic treatment. Eyelid retraction and lag on after orbital and muscle surgery.
down-gaze usually resolve when hyperthyroidism is
brought under control. Similarly, many patients with
extraocular muscle involvement improve. Oph- Chronic Progressive External
thalmic problems, such as exposure keratitis, should Ophthalmoplegia
be monitored and conservatively treated during the Chronic progressive externa! ophthalmoplegia is a
course of systemic treatment. Systemic treatment of rare ocular myopathy that affects the extraocular
Graves' disease includes radiation of the thyroid, muscles, levator palpebrae, orbicularis and, occa-
Chapter 8 245

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

Right Gaze Left Gaze

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

In cases n which diplopia and oculomotor


TABLE 8-6. Features of Internudear Ophthalmoplegia restriction persist past the i nitial healing phase, her-
niated orbital tissue must be extracted surgically
from the bone fracture, and then the fracture must
Adducton defect of one or both eyes on attempted
be repaired. von Noorden37 does not recommend
horizontal versions
surgery for patients with orbital floor fractures who
Abduction nystagmus on horizontal verslons Intact
initially have no diplopia or n whom diplopia dis-
gross convergence "m most cases of posterior lesions of
medial longitudinal f asckulus (pons and medulta); appears within 2 weeks after injury. It is important
absent gross convergente in anterior lesons of medial to remember that diplopia after orbital fracture s
longitudinal fasciculus (midbrain) Frequently, vertical not necessarily caused by entrapment of orbital tis-
nystagmus on up-gaze Usoally, absence of strabismus sue; associated extraocular muscle and cranial
in the primary position, although esotropa or exotropia nerve palsy are common.40 Surgical repair of the
seen in a few cases orbital floor is indicated when the forced duction
test shows a mechanical restriction of elevation and
a CT sean reveis entrapped tissue n the fracture.

face hits the dashboard in a car accident. A fracture


usually occurs in the anterior and nasal orbital floor
INTERNUCLEAR AND
where the bone s thinnest and most vulnerable to
SUPRANUCLEAR DISORDERS
mpact forces. The maxillary and ethmoid sinuses
may be involved. (A blowin fracture is also possible Lesions between the nuclei of the third, fourth, and
in this rea, from trauma to the infraorbital rim; the sixth cranial nerves, as well as lesions above these
maxillary sinus can buckle and rupture through to nuclei, are discussed.
the floor of the orbit.39) Marked limitation of eye
movements (elevation and depression), diplopia,
and enophthalmos are common consequences. In Internudear Ophthalmoplegia
many blowout fractures, nternal eye damage may A lesin in the medial longitudinal fasciculus (MLF)
be absent because the fracture itself helps to cush- blocks information from the pontine gaze center and
ion the blow. Of course, after an injury, the eyes the sixth nerve nucleus to the contralateral third
must be thoroughly inspected for macular edema, nerve nucleus. A lesin in this long internuclear path-
retinal detachment, hemorrhage, oculomotor pal- way produces a characteristic set of clinical manifes-
sies, and other possible problems. tations known as ntemuclear Ophthalmoplegia
Depending on the size of the fracture, orbital (INO) (Table 8-6). The patient presents with deficient
contents can prolapse into the maxillary sinus. or absent adduction of the eye on the affected side on
Orbital fat, fascia, the inferior rectus muscle, and attempted versin. In the subtle form, the adduction
the inferior oblique muscle can all become defect may be apparent only as a mild decrease n
entrapped, thereby severely limiting eye move- the velocity of adducting saccades. There s abduc-
ment (often elevation and sometimes depression). tion nystagmus of the eye opposite the lesin on
Hypotropia may be present n the primary posi- attempted versin. The nystagmus may be present in
tion. A small crack in the orbital floor can incar- the abducting eye only, or in both eyes, with the
cerate some orbital tissue, thus causing diplopia abducting eye having a larger amplitude of nystag-
and other symptoms. After a recent blowout frac- mus. The dissociated or asymmetric horizontal nys-
ture, the most conspicuous clinical manifestations tagmus n these patients appears to be a secondary
are swelling and ecchymosis of the eyelids and compensatory response to the weakness of adduc-
periorbital soft tissue. Initially, this swelling may tion and appears not to be caused directly by the
cause a proptosis of the eye, but later, as the swell- central defect.37 I NO is named for the side of the
ing subsides in 4-6 weeks, the loss of orbital fat MLF lesin that s indicated by the eye with deficient
may cause an enophthalmos. Radiologic investi- adduction on conjgate gaze: For example, a left
gation and CT scans of the orbit can provide evi- INO is indicated when the left eye lacks adduction
dence about whether an nitial restriction of eye and the right eye shows abduction nystagmus on
movement is due to local swelling or hemorrhage attempted right gaze. In bilateral cases, there is usu-
or to the entrapment of orbital contents. ally abduction nystagmus of both eyes on lateral
Chapter 8 249

FIGURE 8-3Bilateral internuclear ophthalmoplegia.


a. Attempted right gaze showing adduction defect of
left eye and nystagmus of right eye. b. Attempted left
gaze showing adduction defect of right eye and nystag-
mus of left eye.

, 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)

Hypometric saccades in all felds of gaze, but nltially


Common n up-gaze
Deficiency or loss of saccades n up-gaze Saccadic "cogwheel" pursuits Eyelid
Sluggish or tonic dilated pupils apraxia (difficulty in opening) Decreased
Light-near dissociation; good constriction at near blinking Sporadic oculogyric crisis
Convergence-retraction nystagmus with oscillopsia
(increased by rotating optokinetk nystagmus
stripes downward)
Papilledema ess common * may be helpful for tasks in down-gaze (e.g., reading
Disturbances of down-gaze saccades and eating). Prisms or occlusion may be necessary to
Skew deviation bring relief from diplopia.
Eyelld retraction (Collier's sign)
Fourth nerve palsy (trochlear palsy) ; Parkinson's Disease
Loss of up-gaze pursuits Parkinson's disease is fairly common (0.1-1.0% of
the population) and has conspicuous systemic and
ocular manifestations. It usually occurs with od age.
The condition stems from a depletion of the neu-
papilledema. Some other causes are tumors of the rotransmitter dopamine secondary to the death of
pineal gland or in the regin of the aqueduct or nerve cells in the substantia nigra, a basal ganglion
superior colliculus, neurosyphilis, mltiple sclero- nucleus of the upper brainstem. The specific causes
sis, trauma, and stroke.12 In cases of sylvian aque- of nerve cell death are many, including carbn mon-
ductal stenosis, signs and symptoms usually are oxide poisoning, viral infections, arteriesclerosis,
idieved by surgical nsertion of a shunt to promote syphilis, and tumors; t may even be part of the nor-
ihe flow of cerebrospinal fluid. Although tumors in mal aging process in some people. Parkinsonian
ihis rea often are inoperable, they frequently patients lose control of muscular activity. They trem-
espond well to radiation therapy. The long-term ble at rest and have trouble with fine motor coordina-
survival rate for these patients s general ly good.44 tion. There is often muscular rigidity, stiffness, and
slowing of movements. In advanced cases, balance,
Progressive Supranuclear Palsy posture, and walking are affected; patients often
Progressive supranuclear palsy is a generic label for a adopt a hurried, shuffiing gait. Physical articulation of
number of rare, degenerative diseases with similar speech becomes difficult, and facial expression flat-
features that affect pursuit and saccadic eye move- tens. Early n the course of the disease, conjgate sac-
ments, the best known of which is Steele-Richardson- cadic eye movements become hypometric n all
Olszewski syndrome. Affected patients typically are fields of gaze, but up-gaze usually is affected initially
seen in the sixth or seventh decades of life with (Table 8-8). Jerky, "cogwheel" pursuits are seen.
reports of being unable to move their eyes into down- Patients may also have difficulty opening their eyes
gaze. The ophthalmoplegia progresses to loss of vol- (i.e., eyelid apraxia), and the rate of blinking
untary up-gaze saccades, loss of horizontal saccades decreases. Reports of diplopia often are associated
and, finally, loss of pursuit eye movements. The ocu- with convergence weakness and a developing con-
bmotor dficits are often compounded by a stiff vergence insufficiency. Later n the course of this
neck. Vestbulo-ocular reflexes usually are intact, but slowly degenerative condition, the eyes may periodi-
severe neck rigidity may make their demonstration cally go into oculogyric crisis, in which they are
difficult. As the disease progresses, patients may locked n an extreme field of gaze for a few minutes
develop strabismus and diplopia, loss of facial up to a few hours.
expression, and dementia. These patients usually There s no known cure for Parkinson's disease.
have a progressive downhill course and die 8-10 Drug therapies have not proven successful as yet.
years after the onset of signs. Ocular manifestations Therefore, treatment addresses symptoms and s
aretreated symptomatically. Yoked base-down prisms directed toward support and comfort. There are
252 Chapter 8

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

UBLE8-10. Characteristics of TABLE 8-11. Characteristics of Voluntary Nystagmus


tiysiologic Nystagmus

Type Pendular saccades; conjgate


Jerk; conjgate
Direction Horizontal
:ion Usually horizontal; fast phase
Constancy Occasional, dependent on conscious effort,
of jerk toward side of gaze cannot be sustained for more than 30 seconds
ancy Occasional, usually whert tred at a time
sncy Rapid Small, may be unequal Frequency Very rapid oscttlations, 3-43 Hz
ilrtude n each Amplitude Usuay sroall 2 or 3 degrees
eye Occurs in extreme
Field of gaze Usuatly initiated by a convergence eye
I of gaze horizontal movement, probably accommodattve
fields of gaze beyond 30 convergence
degrees, occasionally in Latent component None
vertical gaze Can occur in OsciHopsia, rnay be associated with
Symptoms
t component extreme field of malingering symp-toms (e.g., blurred
gaze when binocular visin visin)
is broken None None Associated condtions None
toms ted Specifc mechanism unknown Etology Not a true nystagmus; back and
conditons but apparently caused by forth saccades without an
extreme general fatigue intersaccadic intervat; ability
Common conditon relieved possibly hereditary
by rest or sleep; no other Comments A trick of the eyes that is quite fatiguing, so
nts therapy recommended the oscillation bursts are of short dura-ton,
prevalence is approxi-mately
8%; may be associated with
malinger-ing behavior in
school-aged children
nystagmus becomes abnormal on modrate lateral
shifts of gaze. This condition is used by law enforce-
ment officials as an ndication of whether a driver s has demonstrated that voluntary nystagmus can be
operating a vehicle under the influence of alcohol. part of a spasm of the near reflex if a patient volun-
Other common types of physiologic nystagmus tan ly crosses the eyes.
Ihat the clinician must recognize as normal are The clinician can usually distinguish voluntary
47
OKN and vestbulo-ocular nystagmus. nystagmus by its distinctive features. The oscilla-
tions appear pendular ("saw-tooth"), conjgate,
Voluntary Nystagmus horizontal, and rapid (3-43 Hz) and are usually of
Voluntary nystagmus might more properly be called small amplitude and short duration, due to their
voluntary flutter, because t s not a true nystagmus. fatiguing nature. The rapid oscillations of spasmus
H is a series of rapidly alternating saccades, usually nutans might be confused with voluntary nystag-
initiated willfully with a convergence movement, mus, except that spasmus nutans presents in
and represents nothing more than a trick with the nfancy, not in school-aged children. Furthermore,
48
cyes (Table 8-11). This voluntary flutter s accom- spasmus nutans is much more sustained. Voluntary
panied by oscillopsia and s quite fatiguing. It can nystagmus, therefore, should be easily recognized.
be sustained for only a short period, 30 seconds or
less. Approximately 5-8% of the population can Congenital Nystagmus
demnstrate voluntary nystagmus, an ability that
49 The most common type of nystagmus s congenital
seems to run in families. It s unlikely that pre-
nystagmus, apparently affecting men twice as fre-
sehool children would discover this ability but,
occasionally, an older child has used this eye
maneuver as part of mangering behavior, an emo-
50
tional episode, or an hysteric reaction. Cuiffreda
254 Chapter 8

TABLE 8-12. Characteristics of Congenital (Infantile) Nystagmus

Type Pendular or jerk {or both); conjgate


Directon Consta ncy Usually horizontal, rotary, rarely vertical; fast phase of jerk toward side of gaze
Frequency Amplitude Usualty constant but can occasionally become quiet
Field of gaze Latent Variable, increases witt peripheral gaze
cornponent Variable, creases with peripheral gaze and effort
Symptoms Often dampens with convergence and 10-15 degrees to one side (nult point)
Usually present; increased amplitude and f requency with occlusion of either eye
Associated conditions GeneraPy, redyeed acuity to varying degrees; in many patients, cosmetic concerns,
head turns, rhythmk head movements
Esotropa (common); amblyopa; modrate to high astigmatism; head shaking; 40%
Etlology defectve vestbulo-ocular and optoknetic nystagmus; occaslonal paradoxical
response to optokinetic nystagmus
Congertital; specfic mechanrsm unknown; can be afferent or efferent pathway
Comments lesions; often hereditary pattern (X-linked, autosomat dominant, or others); effer-
ent type possibly a defect ! the pursuit system at the leve! of the brainstem
Irnprovement of condition wtth age; improvement of acuity and cosrnesis possible at
any age with spectacles, contact lenses, prisms, visin trainng, or auditory blo-
feedback

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

TABLE 8-13. Characteristics of Spasmus Nutans

Type Pendular, eyes often asymmetric n amplitude


Directon Usually horizontal, can be rotary or vertical
Constancy Constant or ntermittent
Frequency Fast, 6-t1Hz
Amplitude Small, approximately 2 degrees; eyes often asymmetric; appearance of rnonocularity in
some because of asymmetry Present n alt fields but variable with gaze None
Red of gaze Latent Usually head nodding or wobbing; abnormal head position {tilt or chin expression) in
component 50% of cases Usually none; benign; occasionaJIy, esotropa or amblyopia; a rare
Symptoms association with
1 i ornas
Associated conditions Mechanism unknown, may be hereditary Onset not at brth but usuaiy develops in
first year of lfe; often lasts 1 or 2 years, then
Etiology disappeare with no permanent conseqoences; no treatment indcated; computed
Comments tomograpWc sean recomrnended to screen for glomas

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)

, ', . Haza Partic , ' " Msete Partic Dowrtbeat


PAN Seesaw Wlystagmus -Nystagrnuspr ; Nystag mus Upbeat Nystagmus Nystagmus
:
Associated Smooth pursut usu- Bitemporal hmianop- Cerebllar; dlsfas,s' ,, Associated with paretic Posterior fossa Mltiple sclerosis,
neurologie ally Impared; sa, septo-optic dys- ejspecally f loccu- strabismus, some- disease hydrcephalus
signs or gaze-evoktd and plasia; seen in some lus tesions, one tmes ophthal-
eonditions down-beat nys- comatose patients %perlatedto meplegia
tagmus possibty after severe bran- vestibular disease
accompanying stern injury
multipte sclerosls,
syphills, head
trauma
Etiology Vestibulocerebel- Sellar or parasellar Lesin in frontal Single-muscle weak- Types: (1) lesin in Compressions at
lum or craniocer- tumor disease of gaze center or ness, paresis, myas- anterior vermis of foramen mag-
vkal disorder, the mesodienceph- brainstem projec- thenia gravis cerebellum or num level
mltiple sdeross, alic junction, tions or pontne medulla; (2) intrin- (Arnold-Chiari
trauma, intoxica- trauma, vascular gaze centers sic medullary dis- malformation).
tion, encephali- disease ease or structural encephalitis,
tis, vascular deformity alcohol, spino-
disease cerebellar
>'' '' lesions, magne-
sium deficiency
Comments Acquired PAN Rare; usually acquired, Same in the two Asymmetry between Nystagmus possibly May be congenital
treated success- although congeni- eyes; f airly preva- the two eyes, which increased by barbi- or acquired;
fully with tal type seen; rise of tent f orm of nys- distinguishes t f rom turates, phenothi- reports of
baclofen (anti- intorting eye and tagmus gaze paretic type; lit- azides, phenytoin improvement
spastic agent); fall of extorting eye tle or no nystagmus sodium (Dilantin) using base-out
may continu in acquired cases, in unaffected eye prisms in specta-
during sleep; can opposite in congen- cles and drug
occur as a side ital cases therapy (clo-
eff ect of some nazepam)
anticonvulsve
drugs
PAN i- periodic alternating nystagmus.
Chapter 8 259

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ances). Fortunately, most of these conditions are sis of orbital soft tissue n Graves' disease based on B-
extremely rare, but the prevalence increases n od mode ultrasonography. Endocrinol Jpn. 1979;26:255-
age. Table 8-15 lists characteristics of vestibular 261.
nystagmus, and Table 8-16 lists the clin cal charac- 18. Day RM. Ocular manifestations of thyroid disease: cur
rent concepts. Trans Am Ophthalmol Soc. 1959;57:572-
teristics of several other rare types of nystagmus. As 601.
a rule, the clinician should be very familiar with 19. Kroll HA, KuwabaraT. Dysthyroid ocular myopathy. Arch
the previously described common types of nystag- Ophthalmol. 1966;76:244-257.
mus. If a nystagmus case does not fall naturally 20. Daicker B. The histological substrate of the extraocular
into one of the common diagnostic categories, muscle thickening seen in dysthyroid orbitopathy. Klin
Monatsbl Augenheilkd. 1979; 1 74:843-847.
refer to Tables 8-15 and 8-16 n an attempt to
21. Kendall-Taylor P, Perros P. Circulating retrobulbar anti-
establish the probable diagnosis. It seems prudent bodies in Graves' ophthalmopathy. Acta Endocrino!.
that all patients having nystagmus, except for phys- 1989;121(suppl2):31-37.
iologic and voluntary nystagmus, should be exam- 22. Scott WE, Thalacker JA. Diagnosis and treatment of thy
ined by a neurologist or neuro-ophthalmologist. roid myopathy. Ophthalmology. 1981 ;88:493^J98.
260 Chapter 8

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.
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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 263 javal and the Jump Vergence Training 271


French School 263 Worth and the Isometric Vergence Training 272
English School 265 Optometric Vision Application of the Various
Therapy 267 Principies 268 Vergence Training Methods 272
Sequence of Vision Therapy 268 Office Training
Genera/ Vergence versus Home Training 272
Training Methods 270 Slidng Open-Erivironment
Vergence Training 271 Step versus nstrument Training 273
Vergence Training 271 Patient Motivation 273 Monitoring
Tromboriing Vergence Training 271 Training Progress 275 Retainer
Home Training 276

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

FIGURE 9-2Louis Emile Javal (1839-1907). (Reprinted with permis-


sion from WB Saunders Co. and CV Mosby Co.)

FIGURE 9-1A mask used n the sixteenth century for treatment of


strabismus (esotropa in this example).
Wheatstone stereoscopes were used for larger
angles of strabismus. Training began with large
peripheral targets that were gradually made smaller
doctors, past and present, in terms of both the time as progress was made in breaking suppression. Javal
he devoted to each patient and the detail of his advocated free-space training at the crossing point
observations. Javal's father, an esotrope, underwent of the visual axes (i.e., the centration point) in cases
one of the early operations for strabismus, the sad of esotropa. The purpose was to crate fusin at
outcome of which was a large consecutive exotro- that point, using a fame as a target, and an aware-
pia. Because he did not want the same fate to befall ness of diplopia of an object placed either in front of
his younger sister, Sophie, who also was an eso- or behind the fixation target (i.e., physiologic diplo-
trope, Javal devised as an alternative to surgery a pia). Vergence ranges along the midline were devel-
series of sensory and motor fusin exercises to oped by moving the fixation target back and forth
straighten the eyes. An excellent summary of the while the patient monitored suppression via physio-
functional training techniques for strabismus used logic diplopia. Bar reading then was used for
by Javal can be found in a book by Revell.1 breaking central suppression. Javal believed that
Javal's first step was to equalize the visin in treatment could be expected to take as long as the
each eye by means of spectacles for refractive duration of the strabismus; in many of his cases,
errors. He then eliminated ambiyopia by occiu- cure was effected after 3-5 years of therapy. Javal's
sion, an idea he probably found in the published remarkable success in many cases, including his sis-
works of the French naturalist Buffon.1 Even after ter's, established the practice of orthoptics. (Table 9-1
ambiyopia had been cured, the use of occiusion to summarizes philosophic approaches to strabismus
treat suppression continued; this was Javal's impor- therapy.)
tant personal contribution. Notable among the practitioners following the
Javal's recognition of the role of suppression in teachings of Javal were Remy and Cantonnet. 1
strabismus was one of the great strides forward in Remy is known for refining Javal's methods of anti-
the field of binocular visin therapy. He used stereo- suppression training and for the development of
scopes for antisuppression training by modifying the Remy Separator (used for divergence training
stereograms with suppression clues. Brewster ste- in eso deviations). Cantonnet introduced the con-
reoscopes were used for small deviations, whereas cept of "mental effort," and his antisuppression
Chapter 9 265

i 1ABLE 9-7. Philosophc Approaches to


cular Vision Training

\ and the French school


atopment of orthoptics as an alternative to
aocular muscle surgery tn cases of strabsmus /
tion of ametropia with lenses ass on
antisuppression techniques Judin of free-space,
centration-point training i and the English school
i!
r of f aulty facutty of fusin as an etiology of
smus
elopment of amblyoscope for sensorimotor i
training
anee of pre- and postsurgkal visin training
ass on early visin therapy intervention rk
visin therapy
Ficant expansin of the scientif ic literatura on
Hiature of binocular visin, its disorders, and
jement by optometrists who adopted the con-
of Javal, Worth, Maddox, and other medical s
sis on ptica! management of binocular con-
using prisms and adds spment of many open-
environment training
FIGURE 9-3Claud Worth (1869-1936). (Reprinted with permission
from WB Saunders Co. and CV Mosby Co.)

sis on training for effitent binocular skills and


wng visual comfort in cases of minimal binocu-
times. With repetition, this mental effort to fuse
jnction, strabismus, and other conditions becomes automatic and reflexive, which is a pri-
mary visin training goal.

ds included the hole-in-hand technique, Worth and the English School


ation of the Wheatstone stereoscope as a The concept that strabismus is caused by poor sen-
training device, and the effective use of sory fusin is largely attributed to an English oph-
/phic targets. 2 Modern versions of these thalmologist, Claud Worth (1869-1936) (Figure
1
ng techniques are discussed in subsequent 9-3).4 Worth wrote, "Thus the essential cause of
ers.
ntal effort is an important factor in the ther-pof
squint is a defect of the fusin faculty." He con-
tended that binocular visin either developed in
:
strabismus.3 It may aid the esotrope in making the early plstic years or did not develop at all.
igence movements. One method for instructing Worth4 believed that the "fusin faculty" necessary
tent to use mental effort involves asking the for binocular visin normally reached full develop-
nt to imagine looking at a distant object ; ment before the end of the sixth year of Ufe and
the horizon. In a similar manner, the exo- that any attempt to train the fusin sense after that
should try to visualize fixating an object y time was futile. According to this philosophy, it is
in a downward position of gaze. Mental wise to begin fusin training as soon as possible in
represents a mental attitude in which the it cases of strabismus. In stressing the importance of
actively attempts to hold the suppression in early detection and treatment of strabismus, Worth
perception and a fused binocular image. stated, "Of the cases of squint in which efficient
training is not a passive process, as is the ring treatment is carried out from the first appearance
of a patch or a compensating prism; rather, nts of the deviation, only a small proportion will ever
are expected to exert a mental effort at all need operation." He believed in treating children
266 Chapter 9

"In children under 3 years of age, this treatment s apt


TABLE 9-2. Obstades in the Reflex Paths for to be rather difficult, though I have succeeded in
Development of Binocular Vision many cases. After 5 years of age, the fusin training
takes longer, and a much less powerful desire for bin-
ocular visin is obtained."4 Worth conceded that
A. Sensory obstacles
some older patients who had had strabismus for a
1, Dioptric obstacles
long time could achieve binocularity as a result of
a. Uncorrected errors of refraction
correction of the deviation. He maintained the con-
b. Opacities of the media
tention, however, that the apparently new develop-
2, Protanged uniocular actvity
ment of fusin was not really new but was present
a. Unilateral ptosis
before the deviation became manifest and that fusin
b. Occlusion for one reason or another (e,g.,
merely was originally too weak to prevent the devia-
Injury)
tion from becoming manifest. The concept of re-edu-
3, Retinoneural obstacles (lesions in the visual
pathways}
cation of fusin still s generally accepted today.
Worth4 believed that a faulty "faculty of fusin"
B. Motor obstacles was sometimes congenital. Today this is recog-
1. Abnormalites of the orbit and adnexa (e.g., nized as a genetic possibility in many cases of
tumor that Is space-takng) infantile esotropa n which there is lack of retinal
2. Conditons affectng one or more of the extrinslc correspondence. Even some nonstrabismic indi-
ocular muscles viduis are missing a particular class of cortical
a. Congenital abnormalities (e.g,, faulty inser- disparity detectors for stereopsis, which is proba-
tlon of a muscle) bly a genetic defect.5
b. Injury, partltularly to lateral rectus muscle n
Worth's philosophy was elaborated by Chavasse,6
birth trauma
who stressed that the development of binocular
c. Contractures in cases of paresis
visin depended on reflexes that require both time
d. Disease of the muscle itself
and usage. Chavasse, however, did not accept
3. Conditions affecting the central nervous system
Worth's concept of a faulty fusin faculty; rather, he
a. Congenital absence of the oculomotor nerves
believed that the mechanism for fusin s present at
or their supranuclear pathways
birth, even in congenital strabismics. He contended
b. Head injury
that n order for the binocular reflexes to develop
c Inflarnmation (e.g., encephalitis) d.
normally, it was extremely important for the infant
Supranuclear lesions
to have the opportunity for early single binocular
4. Decompensation of an extrinsic ocular muscle
imbalance
visin. Worth4 believed that most strabismics had an
nherently weak or absent fusin faculty, whereas
C. Central obstacles Chavasse maintained that strabismus was caused by
1. Psychogenic etiology "obstacles to fusin," sensory, motor, or central. Lyle
2. Hyper- or hypoexcitability of the central nervous and Bridgeman7 have presented a modified outline
system of these obstacles (Table 9-2). Both Worth and
3, Central uniocular inhibition Chavasse were in accord to the extent that any hin-
4, Inability of the infant to learn drance to fusin should be eliminated and treated
Source: Reprinted with permission from TK Lyte, G] Bridgeman. as quickly and early as possible.
Worth and Chava$se'$ SquintThe Binocular Refeces and the Chavasse6 emphasized the need to elimnate
Treatment of Strabismus, 9th ed, tondon; Balliere, Tindall and obstacles by means other than orthoptics, namely
Cox; 1959.
optical and surgical procedures. As a result, many of
his followers became disinterested n the functional
training approach to strabismus. Ths negative influ-
3-5 years od and sometimes younger, provided ence notwithstanding, the overall nfluence of
that they were cooperative. Chavasse can be considered positive. His greatest
He trained the fusin sense by use of the amblyo- contributions were n the rea of the developmental
scope, which he invented for this purpose. The dea aspects of binocular visin. In terms of treatment,
behind fusin training was that good sensory fusin Chavasse emphasized the optical-surgical approach,
crales a "desire for binocular visin." Worth wrote, whereas Worth emphasized sensorimotor fusin
Chapter 9 267

training. We believe that these two approaches are


complementary n the full scope of strabismus visin
therapy: The Worth-Chavasse model of binocular
development and treatment s applcable today. An
amalgamation of the French and English schools of
thought gradually evolved nto what has become the
standard philosophy of orthoptics.
Another English ophthalmologist, Ernest Mad-
dox (1863-1933), incorporated both the surgical
and orthoptic treatment of strabismus. He devel-
oped several binocular testing and training instru-
ments, including the cheiroscope, and trained his
daughter, Mary Maddox, as a visin therapist.8
Together, he and Mary founded one of the first
orthoptic clinics that offered both pre- and postsur-
gical visin training. Mary Maddox became the
first president of the British Orthoptics Association,
a paraprofessional society of orthoptists who assist
ophthalmologists n the management of strabis-
mus. To this day, small paraprofessional groups of
orthoptists are found n most English-speaking
countries, including the United States. Many of
them publish annual journals emphasizing the
diagnosis and treatment of strabismus by surgical
FIGURE 9-4Meredith W. Morgan (1912-1999).
and nonsurgical methods.

tifie works of Fry,11'12 Morgan13'14 (Figure 9-4), and


Optometric Vision Therapy Hoffstetter,15'16 largely completed in the 1940s,
At the beginning of the twentieth century n the substantially formed the basis for modern
United States, optometrists were concerned almost evaluation and management of accommodative-
exclusively with clarity of eyesight. They determined vergence anomalies. Ogle's work17'18 on fixation
refractive error and prescribed lenses that elimi- disparity in the 1950s and 1960s added an impor-
nated blurred visin. In the 1920s, Charles Sheard, tant complementary dimensin. Since the 1930s,
a biophysicist at the Ohio State University College clinicians such as Brock and Vodnoy designed
of Optometry, designed a 19-point visin examina- many open-environment training instruments and
tion and binocular case analysis procedure using techniques to improve accommodative and ver-
phorometry measurements.9'10 His concepts regard- gence skills. This continuous scientific and clini-
ing binocular visin were n harmony with the sci- cal tradition, reaching back into the nineteenth
entific tradition of Helmholtz, Donders, Javal, century, has come to be known as classic opto-
Worth, and Chavasse. Sheard's contributions set the metric case analysis and management.
stage with i n academic optometry for the conceptual During the 1930s, A. M. Skeffington, a practic-
framework and the measurement of the zone of ing American optometrist, founded a postgraduate
clear, single, comfortable, binocular visin. education organization, the Optometric Extensin
Optometrists' interest centered on the evalua- Program. Skeffington promoted a holistic concept
tion and management of nonstrabismic binocular of visin and its development that stressed how
anomalies. They realized that visin problems environmental demands might cause disorders of
and symptoms of many patients stemmed from visin (abnormal adaptations) and modify human
deficient binocular skills. The visin training tech- behavior. A lasting influence of Skeffington's ideas
niques of Javal, Worth, and Maddox were elabo- and the Optometric Extensin Program perspectiva
rated, modified, and applied to anomalies of with i n optometry is the concern for visin effi-
vergence and accommodation in cases of hetero- ciency and enhancement. Optometrists now rou-
phoria, as well as to strabismus. The later scien- tinely measure how accommodation, vergence,
268 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

is initiated.20 Some believe that all monocular


motor responses should be mproved maximally TABLE 9-3. General Sequence of Vision
before binocular techniques are introduced; others, Therapy for Strabismus
however, prefer to mplement binocular along with
monocular techniques. In this respect, we are not
Ametropia correction; prisms and added tenses, f fi
rigid n our therapeutic approach. We recommend normal fusin can be achieved ~"-^
that an attempt be made initially to mprove monoc- Amblyopia therapy, visual acuity to at least 20/60 (6/18)
ular fixation skills and the acuity of the amblyopic Anomalous retinal correspondence therapy, if prog
eye to the 20/60 (6/18) level or better. If progress nosis for its elmnation is favorable
becomes stalled at a poorer acuity level, we con- Antsuppression therapy, if normal retinal corre
sider introducing binocular techniques earlier, par- spondence, to establish awareness of diplopia
ticularly in anisometropic patients, in an attempt to Sensorimotor fusin enhancement, if normal retina!
continu momentum n the visin therapy program. correspondence, for good stereopsis and fusional
When some progress is made, monocular tech- vergence ranges
niques can be reintroduced. (See Chapter 10 for a Surgical procedures to reduce the angle of deviation
complete discussion of amblyopia therapy.) to within the range of reflex fusiona) vergence, if
Once acuity has been improved to at least the necessary
20/60 (6/18) level, the state of correspondence Development of good oculomotor and binocular
becomes the mmediate concern. If normal retinal efficency skills
correspondence (NRC) exists, the practitioner can Mantenance home exercises and periodic progress
proceed to deal with suppression, which s the checkups
next step in the sequence. However, f the patient
has anomalous retinal correspondence (ARC), a
major decisin must be made at this point. In a skilled strabismus surgeon in the hope of achiev-
many cases of strabismus of early onset, ARC can ng a cosmetically acceptable result. Postoperatively,
be an insurmountable obstacle to establishing nor- these patients are closely monitored for changes in
mal binocular fusin and bifoveal fixation. Patients the deviation or a recurrence of amblyopia.
who show horror fusionis on such binocular instru- On the other hand, f there are indications that
ments as the amblyoscope have a poor prognosis ARC can be eliminated with visin therapy, we
for developing good binocular visin with visin prefer to attempt a functional cure of the strabis-
therapy. Also, if ARC is present on all tests (e.g., mus, which means that there will also be a cos-
afterimages, amblyoscope, and Bagolini lenses), metic cure. Certain patients respond well to ARC
the prognosis for its elimination with visin ther- therapy (e.g., the small-angle comitant esotrope
apy s usually poor. In such cases, we do not rec- using the divergence training technique n the
ommend binocular training. The large nvestment major amblyoscope, most comitant exotropes, and
of time, effort, and expense often s not justified by most other esotropes with minimally embedded
the anticipated results. There s also the possibility ARC). (See Chapter 11 for a discussion of ARC
of causing intractable diplopia n some cases, par- therapy indicators and techniques.)
ticularly in adults. The next step in the sequence of strabismus
In the case of a strabismic patient with a poor management s antisuppression training. When a
prognosis n whom amblyopia has been partially or patient has gone through ARC therapy, usually rel-
totally eliminated, interventions now are used to atively little suppression remains. ARC is a form of
prevent regression of acuity and fixation skills. A binocular visin, an antidiplopia mechanism; rela-
monovision prescription (spectacles or contact tively little suppression is necessary. Techniques
lenses) may also be prescribed to promote altrnate used to remedate ARC are also powerful antisup-
fixation. (See the discussion on optical penalizaron pression methods, so by the time NRC is firmly
in Chapter 10.) Occasional direct occlusion may be established, central suppression usually has been
recommended to maintain the good results, particu- eliminated. However, most strabismic patients n
larly n young patients. If the strabismus s borderline whom NRC s part of their original diagnosis have
cosmeticaliy, reverse prisms may be prescribed to developed suppression to prevent diplopia. These
crate the appearance of straight eyes. In cases of a patients, as well as those who have gone through
large angle of deviation, we often refer the patient to monocular amblyopia therapy, usually require an
Chapter 9 271
Chapter 9

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

iques n process. The home supervisor must be Open-Environment versus


capable of effective, supportive communication Instrument Training
with the child to maintain a high level of motiva- Whenever possible, the practitioner should assign
tion and compliance. In older children who lack open-environment training techniques as opposed
sufficient self-discipline or effective adult supervi- to nstrument training. Closed-box type instruments
sin in the home, relatively frequent office visits such as the amblyoscope, Brewster stereoscope,
are required to achieve a successful visin training and cheiroscope have some inherent disadvan-
outcome. tages. They often stimulate spurious accommoda-
For a home training program, we usually assign tive and vergence responses. Also, visual skills
three different training techniques each week. learned inside an instrument do not always transfer
Patients tend to become bored with only one or well to the open environment. For example, t is
two techniques and overwhelmed or confused if preferable and more effective to train an exotropic
given more than three. At least one technique patient to fuse at near fixation distances using gross
should be changed each week to add variety, convergence techniques rather than working on
build motivation, and promote generalization of vergence ranges around the angle of deviation in
the learned skills. Initially in a training program, an amblyoscope.
fairly easy training techniques should be assigned Nonetheless, an amblyoscope or Brewster ste-
so that the patient will experience some early suc- reoscope has its place n many visin therapy pro-
cesses. The patient must demnstrate the ability to grams. These Instruments are particularly effective
perform each technique correctly to the doctor's in establishing NRC n cases of ARC, breaking sup-
or visin therapist's satisfaction before it is assigned pression, and n building fusiona! vergence ranges.
for home use. In our clinics, written instruction Vision training for esotropes and amblyopes often
sheets for each exercise are given out to help involves the use of an amblyoscope or other box-
patients remember the proper way to perform type instruments, but most other binocular visin
each technique. (Specific examples are provided anomalies can be managed more efficiently using
in Part Three.) open-environment instruments and techniques
We require a mnimum time commitment of 20 (e.g., televisin trainers, Vectograms, Tranaglyphs,
minutes per day of active training effort during the and prism flippers).
home therapy program. In this way, each tech-
nique is practiced for approximately 7 minutes
each day. In the case of vergence dysfunction, it is Patient Motivation
preferable and more effective to conduct two or Proper patient motivation is indispensable to the
three short training sessions at different times success of a visin training program. For patients
each day rather than to assign one long daily ses- without a real desire for success, compliance with
sion.23 Some patients, due to favorable schedules visin training techniques falters and fails. For
and good motivation, can find and commit more many adults, particularly those who are well edu-
time than 20 minutes each day to active visin cated, simply knowing that they can overeme
therapy. This commitment is, of course, desirable their binocular deficiency or ameliorate their
and to be encouraged. Some of our strabismic visual symptoms is motivation enough to comply.
patients have routinely completed 2 hours of Nevertheless, some adult patients who would oth-
visin training each day for a 3-month period. erwise qualify for a binocular cure with visin
This level of time commitment from the patient training may not want to make the prerequisite
should be voluntary and not demanded by the effort or cannot find enough time in their busy
doctor. Before initiating a home-based visin schedules. For these patients, everything that can
therapy program, the patient needs to review his be done with lenses and prisms should be done.
or her weekly schedule realistically and to com- The doctor should simply explain to the patient the
mit the required amount of time to the program. If condition and treatment options, make appropriate
a realistic appraisal reveis that regular home recommendations, and then give the patient time
training sessions will be difficultto achieve due to to make a considered decisin.
unavoidable circumstances, then two or three in- Preschool and elementary school children usu-
office training sessions conducted each week may ally comply with visin therapy to please the par-
offer a better solution. ents or the doctor. The doctor's rapport with the
274 Chapter 9

formed correctly at home. The visin therapist


TABLE 9-5. Ways to Build Rapport with a Child n must also be responsive to the patient's complaints
a Vision Training Program and expressions of frustration. Often, the doctor
who s\mp\Y \\stens and acknowledges a patient's
Design a child's crner in the patient's waiting rea complaint provides sufficient encouragement or
equipped with a table, chairs, games, cotorng continued effort. Other times, instruments or appli-
books and reading books. cations of techniques must be changed.
Take a personal interest in the chlld as a unique Indi- Another important aspect of building motivation
vidual. Ask about interests, hobbies, pets, games, in children is the use of rewards. Ideally, the visin
likes, and dislikes, Write these n the record and refer training activity itself should be reward enough.
to these on future occasions. The child should want to perform the task or exer-
Modify the training activities to reflect the child's cise because it is challenging, rewarding, and
individuality. enjoyable. However, many children find some
Post on a conspicuous bulletin board the ame and visin training techniques too challenging, boring,
a photo of each child n visin training. or unpleasant. The doctor's goal should be to use
Ask the chiid to make a drawing or painting that can rewards so that the child's attitude approaches the
be posted on the bulletin board.
ideal. One good place to start is to try to incorp -
rate the child's enjoyable activities into the training
program. In cases of strabismus, every attempt
child in visin training is critical for success. When should be made, with optics and active training, to
working with a child n a visin training program, get the patient fusing at least part of the time n the
the doctor should spend time and energy building open environment. If the patient s heterophoric,
a relationship characterized by respect, caring, so much the better. To build accommodative and
personal knowledge, and fun. Each doctor has his vergence skills, the training targets become the
or her unique way of establishing rapport with televisin, a favorite toy, an exciting story or comic
children. Table 9-5 lists some recommendations n book, or a computer game. Appropriate powers for
this regard. flipper lenses and prisms can be used with these
A critical skill in building motivation is effective targets while the child engages in a desired activ-
communication. In working with children, the ity. As t happens, many games and fun activities
doctor must remember that he or she is talking can be effectively used for ambiyopia therapy
with children, not small adults. The language used while the child is occluding the dominant eye. (See
needs to be age-appropriate. Vision training tech- Chapter 10 for a description of ambiyopia training
niques and instructions should be matched to a techniques.) The clinician should look for opportu-
patient's cognitive level and understanding. For nities to incorprate the child's prized activities,
example, chiastopic fusin in the open environ- interests, and games into the training program.
ment usually is an unrealistic technique for a child When standard training instruments and targets
younger than 7 years, who is in Piaget's preopera- are used, boredom can be diminished by applying
24
tional stage of cognitive development, but a the technique within a specified time frame, as dis-
three-dot convergence card can usually be mas- cussed earlier, and by using a pointer stick to touch
tered at this stage. targets. Frequently varying techniques or instruments
The goals of each technique must be clearly s important, because variety remains the proverbial
stated and understood by the patient. We find that "spice of I fe." Also, verbal rewards, tokens, or prizes
if goals are put within a time frame, the technique are motivational techniques often underused by par-
often proves more effective. For example, the goal ents, teachers, employers, and visin therapists. Most
of a jump vergence technique (between a wall adults work for interest, money, goods, services,
clock and a favorite small toy placed just beyond acknowledgment, and other expressions of apprecia-
the NPC) might be to count the number of jumps tion. Children also need reinforcers when they per-
completed in 1 minute. A minimum of six 1 - form demanding and sometimes unpleasant tasks.
minute sets are to be completed and recorded Many types of rewards can be used as reinforcers
each day, with the goal of increasing the number of to shape a child's behavior, altitudes, and skill learn-
jumps (per set). A printed instruction sheet is given ing. This point was made repeatedly in psychologi-
to the parent to ensure that the technique is per- cal research on learning theories in the 1960s and
Chapter 9 275

1970s.25 Some general conclusions from that work


may be applicable to visin training. Learning any TABLE 9-6. Rewards for Children in Vision
ew skill seems to progress most rapidly and effec- Training Programs
tve\y when the demand response is rewarded
immediately, frequently, and regularly. Initially, little
Use immediate rewards to shape behavior: stickers,
steps in the correct direction are reinforced; later, beads, small toys, marbles, peanuts, raisins, cereal.
larger steps toward mprovement are rewarded. As Videotape the chitn training and show the tape to
skills, behaviors, and altitudes are shaped and cor- the child afterward as a reward.
ectly learned, the most effective reinforcement Show the child a magic trick once weekly. After the
schedule of rewards seems to be intermittent and child has faithfully completed home training, give
ariable.26 The visin therapist may want to apply hiin or her the trick and demnstrate how It is done.
Aese Skinnerian concepts in a concerted way if the AHow a child who has participated well n an in-
j child seems to be losing nterest, slacking n effort, office visin training session to pick a prize from the
r making slow progress during the training pro- treasure chest. Allow him or her to take another
gram. Table 9-6 lists several rewards to which chil- prize for a f riend if horne training was also com
en have responded that have resulted in pleted.
fceightened motivation n a visin therapy program. t,et the child earn coupons for desired minor tems:
Bewarding children for cooperating in visin ther- ice cream, hamburger, toy, book, a movie, etc.
py should not be considered a bribe. Children Ask the parents to agree to purchase some desired
often find visin training difficult and demanding; mafor tem (e.g., skates, a wagn, or a bcycle) for
the child at the end of the training program, pro-
ierefore, a parent or visin therapist should reward
vded sufficient tokens have been .collected. The
achild's effort, endurance, and self-discipline.
child earns the prize by collectng a pre-established
A number of computer-based visin training pro- number of tokens (e.g., 50) during the program, A
ffams are commercially available. Two popular sys- token is given when the therapist wants to reward
leins are Computer Orthoptics and Computerized the child's behavior.
AkJed Vision Therapy (see AppendixJ). These pro- Post a progress chart on a wall. One popular versin
garns are designed to break suppression, ncrease is a trip through the solar system in which the child
fcisJonal vergence ranges and facility, improve receives a prize each time his or her rocket ship
accommodative skills, train oculomotor skills, and lands on a planet.
enhance certain perceptual skills. The training tasks Present a computer-generated certifcate of comple
oten are structured n an nteractive game format, for tion bearing the child's amesuitable for framing,
wtiich children seem to have a natural affinity. Some of course.
parents believe that computer games have become a
national obsession. Although the addictive quality of
fese games may be some parents' nightmare, com- of his or her visual condition and training progress
puter visin training just may be the visin therapist's at every stage of the program. Most of the targets
dream come true. In our clinics, we have successfully used n visin training provide means by which to
used computer visin training with children as a monitor sensory and motor fusin status (e.g.,
highly prized reward for home training compliance checks for suppression and stereopsis). Afterimage
and after the completion of other difficult in-office or Haidinger brush foveal tags are examples of
tEchniques. The enormous potential of computer visual feedback ndicators for fixation accuracy.
visin training, for office and home, is being realized. Buzzing devices provide auditory feedback for
In summary, we believe that a visin therapist can correct or incorrect responses. For example, the
successfully maximize a patient's motivation to Franzbrau Coordinator and the WayneTalking Pen
particpate fully in a visin therapy program by are auditory feedback instruments used n the
building rapport, communicating effectively, and development of eye-hand coordination while one
using rewards judiciously. works on pursuits and saccades. Furthermore,
some of the new computerized visin training pro-
grams have incorporated auditory as well as visual
Monitoring Training Progress feedback indicators. Pointer sticks are used with
An mportant principie of visin therapy s provid- many training techniques to provide tactile-kines-
ing the patient with feedback regarding the status thetic feedback (e.g., placing toothpicks n a soda
276 Chapter 9

independent evaluation of therapy progress. The


TABLE 9-7. Objectives for In-Office Monitorng of a remainder of the office visit can be spent perform-
Home Vision Training Program ing directly supervised training techniques that are
not feasible at home and teaching the patient new
home training techniques. An in-office monitoring
Review weekly home training progress, perfor
mance, diffculties, symptoms, questions, and com-
or training visit usually lasts approximately 45
pliance. minutes. The patient may not be required to per-
Directly observe the patient performing the assigned form the home training exercises that day if effec-
home training techniques and offer advice. tive in-office training is done and home training
Give motivational support to the patient and home compliance has been satisfactory.
training coach, if there is one,
Evalate progress in the training program using Retainer Home Training
both standardized and informal testing and modify
the program accordingly.
The last important principie of binocular visin
Thoroughly instruct the patient (and at-home coach
therapy that we address in this chapter is the need
or helper) in new home techniques for the upcom-
to prescribe some means by which the trained
ing week. patient can monitor any regression of learned
skills. The literature indicates that in most cases of
heterophoria and vergence insufficiency, one can
expect to see little clinically significant regression
straw in amblyopia therapy). Continuous eedback if the patient has been sufficiently trained to meet
to the patient is fundamental for effective visin high relase criteria.27"29 (Specific relase criteria
training. for each condition are in accord with criteria in
The doctor must receive accurate and frequent Chapter 2 and are discussed in subsequent chap-
information about the patient's home training ters.) If a patient is released from therapy before all
progress. With in-office training, the doctor or ther- the criteria have been satisfactorily met, regression
apist is present to observe the patient's perfor- can occur with i n a year or two.28 In cases of
mance, but monitoring home training must take a amblyopia and strabismus, some regression may
different form (Table 9-7). At each office visit, the be expected over time. For these reasons, all
doctor or therapist must carefully question the patients should be given at least one home training
patient about symptoms, reports of dissatisfaction, technique and monitored periodically for regres-
compliance with prescribed therapy, performance, sion. If regression of skills is observed, the patient
and any difficulty experienced. The patient should can implement one or two prescribed home train-
return with a completed home training recording ing techniques, 20 minutes per day, for 1 week or
sheet of each day's progress and review it with the so, as needed. If the previously achieved level of
therapist. The patient should also demnstrate performance is not met within 1 week or easily
each of the techniques used at home the previous maintained thereafter, the patient should return to
week so that the therapist can make suggestions the doctor for additional visin therapy. When the
and corrections to improve performance. VVe want doctor suspects that regression is inevitable,
to emphasize this point: Some doctors prescribe retainer exercises can be prescribed on a reduced
home training techniques and, assuming that the but regular schedule, indefinitely.
patient fully understands each, then schedule the Many other important principies of visin ther-
patient for a progress visit in a month. In most apy will be discussed in subsequent chapters
cases, this is a recipe for failure and patient frustra- focusing on specific binocular conditions. Spe-
tion. Careful and frequent monitoring of a patient's cific examples of the principies discussed in this
progress is the only way to ensure effective home chapter are found in the chapters on therapeutic
visin training. The patient's motivation level management.
should also be assessed at each office visit. Motiva-
tional support for the patient and the home training
coach, if there is one, should be sincerely offered
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439^44. ton, 1991.
chapter io / Therapy for Ambiyopia

Management of Refractive Error 280 Bangerter's Method 306 Cppers'Method


Occlusion Procedures 281 Direct 306 Efficacy of Pleoptics 307 Practica!
Occlusion 281 Preventing Occlusion Pleoptic Techniques 308 Vodnoy
Ambiyopia 283 Types of Occluders 284 Afterimage Technique(T10.l9) 308
Motivation and Patching Management 285 Cppers Home Pleoptics (Ti 0.20) 308
Patching Progress 285 Efficacy of Binocular Therapy
Occlusion for Ambiyopia 309 Anomalous
and Ambiyopia Therapy 286 Retinal Correspondence
Penalization 287 Penalization Methods Considerations 309 Suppression and
287 Penalization Management 289 Ambiyopia 310 Antisuppression
Efficacy of Penalization 290 Levodopa Techniques for Ambiyopia Therapy 310
Treatment 291 Red-Filter Therapy and Red Filter and Red Print (T10.21) 310
Occlusion 291 Prism Therapy and Visual Tracking with a
Occlusion 291 Short-Term Occlusion 292 Brewster Stereoscope (T10.22) 311 Bar
Monocular Fixation Training 293 Fixation Reading and Tracking (T10.23) 311
and Ocular Motility Activities Recommendations
(without Foveal Tag) 294 Eye- for Binocular Training 312
Hand Coordination Techniques Progress in Ambiyopia Therapy 312
294 Resolution Techniques 297 Case Examples 313 Case 1: Adult
Foveal Tag Techniques 300 Anisometropic
Preparation for Ambiyopia 313 Abstract 313
Haidinger Brush Training 301 Case History 314 Clnica! Data
Preparation for 314 Impressions and Diagnosis 314
Afterimage Transfer Training 301 Vision Training Plan 315 Monocular
Foveal Tag Training 302 Basic Central Fixation Training 315 Binocular
Fixation Training (T10.13) 302 Training 316 Summary of Results
Steadiness of Fixation Training 317 Disposition 318 Case 2:
(T10.14) 302 Saccadic Movements Anisometropic and Strabismic
with Foveal Tag (T10.15) 303 Ambiyopia 318
Foveal Localization with Abstract 318
Fast Pointing (T10.16) 303 Pursuits with Case History 318
Foveal Tag (T10.17) 304 Resolution Diagnostic Findings 318
Practice with Foveal Tag (T10.18) 305 Diagnosis 319 -.,
Pleoptics 305 Management and Results 319

<
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

TABLE10-2. Classifcatin of Ocdusion Variables fer


A. According to rea of visual f ield occluded
1 oa
1, Total (one eye completely monocular)
2. Partial (only a portion of visual field of either or o-
both eyes occtuded)

8. According to the effect on light transmisin t.


Opaque
a. Bandage (adhesive) patch
b. Tie-on patch
e. Ctlp-on patch
2, Attenuating (parta! light transmssion)
a. Neutral-density filters FIGURE 10-1Examples of occluders. a. Bandage patch. b. Tie-on
b. Crossed polarizing filters patch. c. Clip-on patch. d. Opaque contact lens.

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

Care must be taken, however, to avoid occiusion


amblyopia (discussed n the next section).
If the amblyopic patient s older than 6 years,
we recommend the traditional method of direct,
most efficient and effective
opaque occiusion as the nitial choice for therapy.
therapy, but the patch needs to be
For adult amblyopes also, direct occiusion s the
worn alternately, some days directly (on the
most effective single therapeutic choice. Typically,
nonamblyopic eye) and other days inversely (on the
the more time each day that the patient wears the
amblyopic eye). The ratio of direct to indirect
patch directly, the more rapid is VA improvement.
occiusion should vary depending on the chd's age.
When a child attends school or an adult drives a
We recommend using a wearing schedule for con-
car and works for a living, the practical require-
stant, direct, opaque occiusion
ments of these activities for adequate visin unfor-
based on the num-ber of days
tunately limit the occiusion schedule. It must be
corresponding to the chd's
remembered that an amblyopic patient with 207
age followed by 1 day of inverse occiusion (Table
200 (6/60) acuity who s patched directly can be
10-3). For an infant not more than 1 year od, the
considered legally blind. When periods of normal
patch would be alternated on a daily basis. (Note: In
VA are a practical necessity, the patient is allowed
cases of constant infantile strabismus, we also
to wear the patch inversely during those times. As
recommend the use of Fresnel prism glasses worn
a result, the overall treatment period will be longer,
part-time to promote the possible
but this may be a necessary compromise.
development of binocular visin.)
For students and working adults, it s often expe-
According to this patching
dient to postpone amblyopia therapy until vaca-
schedule, a 3-year-old amblyopic
tion, when direct patching can be ntensively
child would be given 3 consec-utive days of direct
undertaken. On vacation, the patient with deep
occiusion and 1 day of inverse occiusion.
amblyopia stays at home, wears a constant, direct
Patients older than 6 years typically do not
bandage occluder, and performs intensive visin
develop occiusion amblyopia with constant direct
training techniques to speed acuity improvement.
Many times, the VA improves rapidly to modrate
or mild levis, so that further direct patching at
school or in the workplace s no longer debilitat-
ing. In cases of anisometropic amblyopia, n which
some binocular visin exposure s desirable, the
patient should try to coordnate activities that
require good acuity with the binocular visin
period (during which the patch s not worn).
It s mportant for al I patients to commit to fol-
lowing a specifically agreed-on patching schedule
before occiusion therapy is initiated. If the patient
cannot realistically find the necessary time for
patching n the daily schedule, then treatment
should be delayed until another time or, possibly,
forsaken.

Preventing Occiusion Amblyopia


When a clinician prescribes constant, total, opaque
occiusion for a patient up to 6 years od, he or she
must remember that the acuity of the patched eye
may deterirate. In infants, the acuity of the nonam-
blyopic eye that s patched can fall almost as
quickly as the acuity rises n the amblyopic eye.4 In
strabismic amblyopia, constant total patching is the
284 Chapter10

TABLE 10-3. Constant Patching Schedule to Types of Occluders


Prevent Occluson Amblyopia (Amblyopia due The type of occluder chosen for a particular ambly-
to Constant Strabismus) opic patient depends on a number of factors (Table
10-4). The bandage occluder and tie-on patch are
opaque and totally exclude light. Most clinicians
prefer these occiuders in the hope that a vigorous
Days of Direct Days of I n verse
Age (yrs) Patching Patching patching program will bring rapid therapeutic
1 1 1 results. The bandage patch conveniently fits under
spectacle lenses. This occluder is taken off at night
2 2 1
and changed daily. At night, a moisturizing cream
3 3 1
(e.g., Nivea ointment) can be applied to the skin
4 4 1
around the eye to prevent or reduce irritation from
5 5 1
the adhesive. Many patients prefer to wear a less
6 6 1
cosmetically obvious patch and cooperate better
7 Constant 0
using a clip-on or translucent occluder. Our prefer-
ence, however, in most cases of amblyopia is to use
a bandage occluder, full- or part-time, depending
patching, no matter how long the patch is worn, on the case. Adults may choose to wear the tie-on
but the clinician should monitor VA of both the patch because it lacks adhesive and is therefore
nonamblyopic and amblyopic eyes in all patients more comfortable; in addition, many come in
undergoing occlusion therapy, regardless of age. If designer colors. A contact lens occluder is our next
occlusion amblyopia does develop during the preference if a child persists in resisting bandage
course of patching therapy, the ratio of direct to occlusion. If neither of these alternatives is accept-
inverse occlusion should be reversed to restore VA. able, penalization (attenuation) methods should be
Part-time, direct patching is applied in cases of considered. Children who resist bandage occlusion
anisometropic amblyopia or intermittent strabis- often look around a tie-on, clip-on, or translucent
mus, 3-6 hours per day, depending on the depth of occluder, thus compromising the therapy program.
the amblyopia. There is no need to altrnate the When peripheral fusin needs to be preserved, as
patching in such cases. in most cases of anisometropia or ntermittent strabis-

TABLE10-4. Types of Occluders

Types Features Advantages Disadvantages

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

33 cm. 33 cm. 33cm. 33 cm.

+3 D AddI
I +3 D Add

1% Atropine 1% Atropine

Normal Amblyopic Normal Amblyopic

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.

Near penalization often is preferred to the other meth-


ods for patients having deep strabismic ambiyopia.
Atropine drops or salve (1 %) is nstilled in the nonam- the atropinized eye and is, in fact, being used for
biyopic eye once daily. The spectacle correction for nearpoint fixation. If it is not, total penalization (see
the dominant eye is worn to give good far acuity and next section) should be considered. Mximum acuity
prevent occiusion ambiyopia. A single-vision, +3.00- improvement usually occurs between 1 and 6 months
D add is prescribed n addition to the refractive cor- after near penalization s initiated.
rection for the amblyopic eye (Figure 10-3). The effect
of this add is to promote clear visin and fixation with Total Penalization
the amblyopic eye for all nearpoint viewing distances Total penalization is a type of direct, graded occiu-
and to blur far distances sufficiently to forc alterna- sion. Both far and near form visin are degraded,
tion to the dominant eye for farpoint viewing, thus but light perception still is permitted. This method
preventing occiusion ambiyopia. The goal is to is used only with high hyperopic patients with stra-
achieve altrnate fixation, but the child must wear the bismic ambiyopia. Total penalization s achieved
eyeglasses to obtain mximum benefit. Near VA by atropinization of and the prescription of only a
needs to be monitored during near penalization to plano lens for the nonambiyopic eye; however, full
ensure that the amblyopic eye has better acuity than optical correction (for the farpoint) s given to the
amblyopic eye. Consequently, the amblyopic eye
fixates objects at both far and near (Figure 10-4). It
is prudent to use this technique only with children
oo aged 6 years or older, to avoid the possibility of
inducing occiusion ambiyopia.

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

therefore, s fogged for viewing at far and is in co CO


33 cm. 33 cm.
focus only for targets at approximately 33 cm.
Also, this eye cannot focus for very near distances
because of cycloplegia. Nothing is done to the
amblyopic eye except correction of any significant +3 D Add I
(spectacles or
refractive error, so that the patient can focus an contact lens)
image with that eye at al I distances. The amblyopic Normal Previously
eye will therefore be used primarily for viewing Amblyopic
distant objects if its VA exceeds that of the fogged
nonamblyopic eye. Binocular visin is possible at FIGURE 10-6Far penalizaron with plus lens.
33 cm, as both eyes are in focus for that working
distance. If there is suppression, active antisup-
pression training techniques (e.g., polarized or eyes in addition to the overcorrection.
anaglyphic reading bars) are recommended to pro- The 16 patients wore these spectacles on altrnate
mote fusin at 33 cm. days for 1-4 years, depending on the child's
age. All patients maintained 20/50 acuity or better
ptica! Penalizaron n the formerly amblyopic eye. The investigators
In cases of strabismic amblyopia that have been recommended maintaining this rgimen of optical
cured or almost cured but n which the strabismus penal-zation until the age of 6-8 years, at which
remains, a form of optical penalizaron may help point the visual system s fairly mature. They
to maintain the good VA results. Some children observed that the recurrence of amblyopia s
need to maintain an altrnate fixation pattern possible as late as the early teenage years n some
indefinitely to prevent acuity regression. This can cases. Therefore, all young patients should be
be achieved by a program of periodic direct occlu- monitored fre-quently for regression and, if it
sion, but optical penalization often is preferred by occurs, optical penalizaron or a short course of
both the patient and the parents. If a +3.00-D single- direct patching (or both) can be reinstated.
vision spectacle add or contact lens s placed
before an eye, that eye will most likely be used for Penalization Management
nearpoint fixation and the other eye for viewing Because atropine can have serious side effects in
farpoint targets. The addition lens usually is placed some individuis, clinicians who use penalizaron
before the nonamblyopic eye to give preference as an occlusion option must be vigilant in screening
for its use at near fixation distances, whereas the patients for signs and symptoms of overdose. Table
amblyopic eye will more likely be used for distant 10-5 lists systemic and ocular signs and symptoms
viewing (Figure 10-6). This represents a monovi- of atropine overdose of which clinicians must be
sion approach to promote habitual altrnate fixa- aware. This is not a trivial concern. There have been
tion. Contact lens monovision corrections have six reported deaths of children aged 3 years and
been well accepted by many presbyopic contact younger due to topical application of atropine
lens wearers with normal binocular visin (85% n drops.35 These children did, however, have some
one study),33 and this method holds much promise central nervous system abnormality or were sickly,
for the long-term management and prevention of so extra caution is appropriate in these cases.
amblyopia n children. It must be remembered that young children can
von Noorden and Attiah34 reported good results develop occlusion amblyopia in the atropinized eye;
in preventing the recurrence of amblyopia in von Noorden36 reported three such cases in children
young children using alternating optical penaliza- no more than 2 years of age. Total penalization is a
tion. Most of their patients, aged 8 years or form of visual deprivation. Because a patient can
younger, had been cured of amblyopia but, post- form the habit of not fixating with the normal eye, a
operatively, had eso microtropia. The researchers
prescribed two pairs of spectacles for use on altr-
nate days. One pair had a +3.00-D overcorrection
for the right eye, and the other pair had the same
overcorrection n the left lens. If there was a signif-
icant refractive error, this was prescribed for both
290 Chapter 10

blyopic eye in +0.25-D steps until the patient can


TABLE10-5. Signs and Symptoms of switch fixation to the amblyopic eye (as indicated
Atropine Overdose by reading letters clued to that eye). The lowest
amount of plus addition needed to switch far fixa-
tion consistently to the amblyopic eye then is pre-
Systemk
scribed over the corrected ametropia with most
Thirst
plus-lens correction. Either spectacle lenses or
Ataxia
contact lenses can be used for optical penaliza-
Fever
tion, whichever s more clinically appropriate.
Sleepiness or insomnia
Dryness of skfn, mouth, and throat Efficacy of Penalization
Red, flushed skin of the face and neck
Cenerally, penalization methods appear to be an
Restlessness, irritability, or delirium
effective alternatve to conventional, direct, total
Tachycardiarapid and weak pulse
occlusion for treating amblyopia and preserving
Urinary retention
good acuity. 38 '39 von Noorden and Milam 40
Ocular reported a series of 17 mildly amblyopic patients
Allergic conjunctivitis, keratitis (all but 1 of whom had an initial acuity of 20/100
Contad dermatitis of eyelids or better) who did not accept conventional occlu-
Decreased lacrimation Increased sion therapy for some reason. Ten patients, ages 2-
infraocular pressure Photophobia 12 years, experienced VA improvement of two
lines or more in the amblyopic eye wth penaliza-
tion, and none showed any deterioration of visin
child must be carefully monitored weekly, or at least in the nonamblyopc eye. These investigators also
every 2 weeks, to ensure that altrnate fixation s reported another group of 13 patients who had
actually occurring with either eye. mproved using conventional occlusion and n
Optical penalization can be an alternative to whom penalization had prevented the recurrence
conventional occlusion in cases of mild amblyo- of amblyopia in all but three cases.40
pia (20/70 or better acuity in the amblyopic eye). Ron and Nawratzki41 demonstrated impressive
This method seems particularly appropriate n results using various penalization methods for stra-
cases of noncompliant patching or n cases n bismic amblyopia with 38 children between the
which a monovision correction is needed to ages of 6 and 12 years, most of whom had modr-
maintain good acuity n each eye. Repka et al.37 ate to marked amblyopia. The average duration of
demonstrated the effectiveness of this method in treatment was 10 months. After a 2-year follow-up
their patient series of 34 anisometropic or strabis- period, they reported good acutes (20/40 or bet-
mic amblyopes. They found that the plus-power ter) in 74% of these patients, with 50% achieving
addition required to make the patient switch fixa- ths level despite initial marked amblyopia. These
tion to the amblyopic eye ranged from +0.75 D to results are even better than those found by con-
+2.00 D, with an average of +1.25 D. This is con- ventional opaque occlusion in young children. The
siderably less plus than was used by von Noorden researchers believed that standard occlusion may
and Attiah.34 For patient acceptance, t is desir- have proven less effective due to unobserved
able to use the mnimum amount of additional peeking or occasonal removal of the patch. They
plus power to crate altrnate far-near fixation maintained cise monitoring of penalization to
while still ensuring that the patient does indeed ensure that the amblyopic eye was being properly
fixate with the amblyopic eye. Repka et al. 37 rec- stimulated.41
ommended using a distant vectographic acuity A large patient series reported by Repka and
chart to determine the effective mnimum amount Ray42 also had a very positive outcome. There were
of plus addition. Patients are tested while wearing 166 strabismc and anisometropic amblyopic chil-
their best farpoint spectacle correction and dren (1-12 years od) who underwent penalization
crossed polarizing (vectographic) filters. As the for at least 3 months. Optical penalization was
patient reads letters on a farpoint vectographic used in 87 cases, and these patients exhibited an
chart, plus-power lenses are added to the nonam- average VA improvement from 20/38 to 20/28. In
the other 79 patients who underwent atropine
Chapter10 291

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

reports ndicated that the same level of mprovement


could be achieved by viewing uniform gray fields or TABLE10-6. Amblyopia Training Activities
merely by direct patching for 7 minutes per day.58The
rotating gratings proved incidental and inconsequen-
Board games (e.g., Serabble)
tial. The acuity mprovement is apparently due to a
Card games: Concentration, Canasta, etc.
rapid learning curve for fixation with an amblyopic
Colorng in Os or vowels ir books and magazines*
eye when that eye s initially forced to fixate with
Coloring books*
direct occlusion. Some of the studies also had the
Comic books
patient practice eye-hand coordination activities
Craft projects; small meterais
while viewing the CAM stimulator through a trans-
Crossword puzzles*
parent overlay. These CAM studies have made clini-
Dot-to-dot patterns*
cians aware that significant mprovement n VA is
Drawing
possibfe n many cases of amblyopia with mmimal
Bammerirrg nails
patching and emphasis on eye-hand training tech-
Jacks*
niques. Griffin et al.59 provided an example by
Jgsaw puzzles
reporting successful results with mmimal patching
Lego and other blocks
and monocular visin training n a case of anisome-
Marta les
tropic amblyopia. Reviews of the literature on the
Mazes
CAM therapy have been conducted by Garzia7 and
Modef-buiWing kits: boats, cars, etc.
Ciuffreda et al.60 In summary, some patching s better
Peg-Board activities
than no patching, yet we must add that rigorous
Perceptual materiais: Frostig, Rosner*
patching often s needed for the best therapeutic
Pfckup sticks
outcome.
Reading any printed materiais*
There are certain cases of amblyopia n which
Sewng clothes
short-term occlusion seems both appropriate and
Shooting games
effective, if t s combined with active visin therapy.
Stringing beads
If a child or adult with mild to modrate amblyopia
Throwng or hittlng games*
finds patching n public unacceptable, successful
Tinkertoys
results may still be possible if direct patching s
Toothpicks in straw
done in conjunction with patient participaron in 1-
Tracing*
2 hours per day of vigorous visin training. Several
Video and computer games*
patient series have demonstrated positive results
with this approach, although the cure rate s not *Authors' 10 best picks.
quite as high as that found n studies using full-time
occlusion.2'27'61'62 These good results probably are due
more to the effect of the active visin therapy than challenging activities that can stimulate and speed
to short-term occlusion only. improvement of VA. Fortunately, many of these
activities are enjoyable for patients of al I ages;
training compliance is usually not a problem. Table
10-6 lists activities that we have found entertaming
MONOCULAR
and effective. These games and activities can con-
FIXATION TRAINING veniently be done at home with a mnimum of
The goals of monocular fixation and motility train- supervisin. We usually ask our visin therapy
ing with the amblyopic eye are to enhance these patients to devote at least 20 minutes per day to
visual skills through conscious patient effort and home training, but when patients engage n many
performance feedback. Direct patching alone of these interesting activities, the home training
forces the patient to practice a certain level of ocu- time usually extends past this recommendation.
lomotor skills, but amblyopic patients, when The clinician must monitor the patient's progress
patched, frequently do not attempt as many critical closely during occlusion and training techniques.
seeing and eye-hand coordination activities as they Patients who have EF, steady or unsteady, may sta-
could possibly perform. These monocular training bilize fixation on the eccentric point rather than
techniques, however, can provide the patient with moving fixation toward or to the fovea. In the rare
294 Chapter 10

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

RCURE 10-8Dyna Vision 2000


efecfronic fixation instrument.

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

FIGURE 10-9Bat and Marsden ball for lat-


erality and directionality training, combined
with occlusion of the nonamblyopic eye.

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.

Visual TracingCM 0.6) Ann Arbor Tracking (T10.7)


Visual Tracing (designed by Dr. Sidney Groffman, Ann Arbor Publishers markets some printed materi-
State University of New York College of Optometry, alsthe Ann Arbor Tracking Program, formerly
New York City) s an excellent method by which to known as Michigan Trackingthat we have found
build the visual skills of an amblyopic eye (see to be both motivational and effective in training
Appendix J for source of training material). The visual tracking. The basic task is to find and circle a
patient looks at a series of intersecting lines, each key sequence of letters, numbers, words, or symbols
of which s connected to a letter on one end and a in a large, seemingly random, set of such. The exer-
number on the other. The purpose s to match the cise s timed, and progress can be charted. The most
number with the appropriate letter as the ambly- useful workbooks for training amblyopic patients
Chapter10 297

RCURE 10-10The Perceptuomotor Pen


>also called the Talking Pen). a. The appa-
tatus. b. Example of its use n visin ther-
apy. (Courtesy of Wayne Engineering.) JtL

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

threshold target size. This is an important step in


the remediation of amblyopia and EF. The follow-
ing techniques are particularly suited for resolution
training and can be introduced at any stage in the
visin therapy program.

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

FIGURE 10-12Example of the Ann


ArborTracking Program.
Chapter10 299

speaking, saccades are rarely greater than 15


degrees without some head movement64 but, for the
purpose of this exercise, to build saccadic accuracy
and speed with the amblyopic eye, the saccadic
demands can be larger. The distance from the tar-
gets controls the resolution requirement. Initially,
the patient would use suprathreshold letters (view-
ing at nearer distances) and later, as training
progresses, threshold acuity letters (viewing at far-
ther distances) would be used.
Introducing a near-far separation of the two tar-
gets (e.g., 40 cm and 3 m) stimulates accommoda-
tive facility. Speed of focusing s emphasized. In
this case, a smaller Hart Chart s used for the
nearer target, as n Figure 10-13.
Rather than relying solely on Hart Charts, some
clinicians photocopy various clinical nearpoint
charts and enlarge them for use n home fixation
training. This provides a range of letter sizes, so
that resolution practice can be conveniently added
to the task. We suggest an emphasis on accommo-
dative training when central fixation exists. The
accommodative system responds optimally when
foveal fixation s used, and responsiveness falls off
quickly with eccentricity of fixation.65'66 However,
the fact that central fixation has been achieved in
an amblyopic eye does not imply that accommo-
dative amplitude and facility are normal. Usually, FIGURE 10-13Hart Chart, large for distant viewing and small for
this is not the case. Accommodative training often near viewing. (Courtesy of Bernell Corp.)
is needed to mprove both amplitude and facility.
(Refer to Chapter 16 for accommodative training
techniques that can also be used for amblyopia.) magazine, newspaper) s held at a threshold dis-
tance from the patient while the patient reads for
Counting Small Objects (T10.9) meaning and enjoyment. The reading period
The counting of small objects requires resolution should be at least 5 minutes for elementary school
and sorting skills. As with all the other techniques children and 10 minutes for older children and
in this section, the nonamblyopic eye is totally adults. The goals are to improve the threshold acu-
occluded. Small objects, such as multicolored can- ity (read the material at farther distances or
dies, small beads, and colored dots on a paper, are progress from large print to small) and to ncrease
chosen to approximate the threshold acuity level the reading time or rate (higher efficiency). This
of the amblyopic eye. The patient is asked to sort technique can, however, be fatiguing and frustrat-
the targets by some parameter (e.g., size, shape, ing, because people ordinarily read print three
color). A pointer stick or tweezers can be used for times larger than their threshold size for optimum
sorting. In the case of dots, the patient can draw reading performance.67
dots of various sizes or colors on a paper. The train- A second reading technique s similar to word
ing task would be to sort and count them on a tracking in the Ann Arbor Tracking Program. The
visual basis without hand support. patient uses personally selected reading material
and circles key words (e.g., the, s, are, she, he, f)
Readingfor Resolution (T10.10)
or certain letters as they appear n the text. Again,
Reading recreational material using the amblyopic the material s held at a threshold distance. The
eye alone should be encouraged for as much time patient attempts each day to increase the number
as is practical. The material (e.g., comic book, of key words or letters dentified and circled within
a prescribed time (5 or 10 minutes).
300 Chapter10

Tachistoscopic Training (T10.11) If VA through a telescope does improve for a


A tachistoscope is a projection device that flashes tar- particular patient on initial testing, then prescrib -
gets (letters, numbers, words) at rapid rates of expo- ing a variable-focus telescope for therapy should
sure (e.g., 0.1 second or faster). The patient does not be considered. The most popular powers are 2.5x
have sufficient time to make a saccadic eye move- and 4x. We tend to keep this technique n reserve
ment from one target to another for recognition and recommend its use only if progress n visin
within 0.1 second. The device usually is used by edu- therapy appears to be stalled using other methods.
cators to ncrease the span of recognition of poor The therapeutic technique s simply to view distant
readers, but this technique is applicable for ambly- objects, words, or televisin with the telescope for
opic patients also. The task s usually performed in approximately 30 minutes a day for 1-2 months.
the office because of the special equipment required. An Al (afterimage) tag can be incorporated effec-
Using only the amblyopic eye, the patient attempts to tively with this method also. The improved fixation
improve the speed (e.g., from 1.0 second to 0.1 sec- pattern and acuity become habitual in some cases
ond) and span (e.g., two-letter words to five-letter and transfer to natural seeing conditions.
words) of recognition and resolution. Targets can be
presented at a threshold size appropriate for the dis-
tance. Many educational supply companies market
FOVEAL TAG TECHNIQUES
tachistoscopes, ncluding inexpensive home training
models with a spring-loaded mechanism. Foveal tag techniques for rehabilitating fixation
A similar technique involves the use of flash and eye motility are among the most effectiv e
cards depicting words or pictures of objects. The visin training methods available to the primary
therapist briefly shows the patient a flash card, and eye care doctor, but their effectiveness still requires
the patient attempts to resolve and identify the word the support of occlusion or penalization. Several
or picture with the amblyopic eye. The cards are ini- clinicians describe the Al transfer technique, in
tially shown at suprathreshold acuity levis and, as particular, as valuable for both in-office and home
68 70
training progresses, at threshold. The goal s to training. ~ We recommend using foveal tag tech-
increase both the speed of recognition and VA. niques as a standard part of therapy for EF. This
method ensures that the fovea s being used cor-
Monocular Telescope (T10.12) rectly for fixation and motility. The tag is an
When some patients with EF view letters or objects entopic projection of the fovea in free space that
with the amblyopic eye through a 4x telescope, provides the patient with visual feedback as to
there is improvement in the fixation pattern and in where the fovea is directed. If the patient attempts,
VA, to a degree that exceeds expectations on the with the amblyopic eye, to make a saccadic eye
60
basis of the magnification factor alone. Assume, movement to a small target and has an undershoot,
for example, that a patient presents with 20/120 VA the patient becomes immediately aware of the
in the amblyopic eye (minimum angle of resolution error. The patient can then develop corrective sac-
[MAR] = 6 minutes). W ith a 4x telescope, one cadic and fixation strategies that become habitual
would expect the patient to read the 20/30 line with time and repetition.
1
(MAR = 1.5 [i.e., /4 of 6]). The patient, however, It must be remembered that when patients with
may read the 20/20 line with the telescope, suggest- EF fixate a target, they believe that they are looking
ing improved fixation. It s not known why fixation straight at it. The oculocentric direction of the
mproves for some patients with a telescope, but amblyopic eye is associated with the eccentric
one theory is that magnification, and particularly point, not the fovea. Therefore, when accurately
the restricted field of gaze, in some way disrupts the fixating a target with the foveal tag, the patient
habitual fixation pattern and promotes foveal fixa- feels that he or she must look off to the side of the
tion. The magnified letters also are more isolated; target. Foveal fixation "feels" abnormal to the
single-letter acuity generally s better than whole- eccentric fixator. Not only s localizaron abnor-
60
line acuity in amblyopia. Guffreda et al. caution mal, but usually all the oculomotor functions of an
the clinician about relying on the magnification fac- amblyopic eye are deficient to some degree.
tor for prognostic purposes. They believe, however, Patients feel that they cannot control their fixation
that the use of a telescope has some merit n the or eye movements accurately, which is true. The
treatment of amblyopia with EF. therapist frequently needs to reassure most patients
ChapterlO 301

FIGURE 10-14Macular Integrity Tester-


Trainer (MITT). (Courtesy of Bernell Corp.)

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

get (e.g., pointer stick) is used to achieve central


fixation. The goal is for the patient to achieve
foveal fixation quickly without a guide target.

Haidinger Brush
. Haidinger brush 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

FIGURE 10-16Rotating Peg-Board for eye-


hand coordination training during direct
occlusion. An afterimage can be used for
feedback to the patient.

Resolution Practice with cations made n a particular period (e.g., 1 or 2


Foveal Tag (T10.18) minutes) and, with subsequent triis, attempts to
The goal of resolution practice with a foveal tag s to ncrease the rate. This technique works well at
increase to its mximum the resolution and identifi- home using the Al tag, because various magazines,
cation acuity of the amblyopic eye. At all stages in books, newspapers, and comic books of nterest to
fixation training, the patient should attempt to resolve the patient are general ly available. For the sake of
threshold letters and object detail. VA peaks at the efficient training, the therapist can supply Hart
fovea in the amblyopic eye.63 Even though that peak Charts or other printed materials and test the
may not be as high as n the nonamblyopic eye, patient to establish the proper threshold training
when the target s on the fovea, resolution is best. The distance.
amblyopic patient who habitually does not use the
fovea for fixation should practice foveal resolution so
that foveal fixation becomes reflexive. The peak acu-
PLEOPTICS
ity at the fovea can become another clue for the
patientto establish central fixation. Increased resolu- Pleoptics s a form of ambiyopia therapy that was
tion and dentification acuity develop with motoric very popular during the 1950s and 1960s but has
mprovements n centricity, steadiness, and accuracy since lost much of its attraction. One of the major
of fixation. Further mprovement n acuity apparently appeals of these methods was the use of inverse
occurs through some sensory adaptation mechanism rather than direct occlusion. Patients patched the
and tuning of the receptive field organizaron, but this amblyopic eye for 1 or 2 months before visin
component is neither well understood or docu- training with pleoptic instruments and during sub-
mented in the literature. sequent therapy. Inverse patching was intended to
The resolution practice technique is the same break the habitual pattern of EF and suppression
using either the HB or Al foveal tag. When the that the patient had established. During this patch-
patient aligns the tag with a suprathreshold or ing rgimen, amblyopic patients, seeing with the
threshold letter, the patient attempts to identify t nonamblyopic eye, could go about their uves basi-
quickly. The patient counts the number of identifi- cally unencumbered by poor visin. The disadvan-
306 Chapter10

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.

FIGURE 10-17Euthyscopc afterimage


advocated by Cppers for eccentric fixa-
tion therapy. a. Negative afterimage
(black doughnut). b. Afterimage with psy-
chological characteristics of a real
object. c. Positive afterimage (white
doughnuf) that vilales the psychological
characteristics of a real object. d. Nasal
eccentric fixation of the right eye. e. Cen-
tral fixation. f. Central fixation using a
small letter as a fixation target.

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

integrity of the fovea, and to provide a foveal tag


for active fixation training with objects n the open
FIGURE 10-18Method of Vodnoy in cases of eccentric fixation. a. The environment.

Vodnoy Afterimage Technique (T10.19)


H -- 1 -- ! ----1 ---1 -- 1 -- h
Vodnoy (B. E. Vodnoy, personal communication,
3 2 1 0 234, 1974) ntroduced a novel home training technique
to produce Ais n the proper position when treating
opaque mask held before a floodlight with ares cut out for viewing by
the right eye with nasal eccentric fixation. b. Fovea (f) being protected EF. The EF point (point e) is dazzled, and the posi-
while point e is dazzled by the are on the right side of the mask. tion of the fovea is identified for proper fixation
training. The patient's EF must first be determined
accurately by some means, such as by visuoscopy
in our opinin, justify the extra effort associated or HB testing. When this has been accomplished,
an Al is produced by putting an opaque mask n
FLOOD LAMP
front of a bright, frosted floodlight (e.g., 100 watts)
(Figure 10-18). A pair of ares is cut out of the mask
so that the distance from the center of the ares to the
center of the mask s the same as that between point
e and the fovea. (Convert prism diopters into milli-
meters at a 40-cm [4-dm] viewing distance by using
the decimeter rule that each 4 mm represents 1A.)
For example, assume the right eye has steady nasal
EF of 5A. While occluding the nonamblyopic left
eye, the patient is nstructed to fixate steadily at the
PATIENT VIEWS illuminated are 20 mm to the right for 30 seconds.
ARC ON RIGHT
SIDE The are dazzles point e, and the are on the left side
of the mask dazzles a temporal extrafoveal point the
same distance away from the fovea. This gives the
patient the advantage of having a bracket as a nega-
tive Al, with the center positioned at the fovea. In
normal room illumination, the patient s nstructed
to put these brackets around any target that the ther-
apist indicates (e.g., an HB to confirm proper align-
with pleoptics. If referral sources for pleoptic ther-
ment of the brackets, Snellen letters of various sizes
apy are not available, we suggest using the cus-
for resolution practice, or any real object for fixation
tom-made pleoptic instruments and visin training
training in free space). If the fixation target s a flash-
techniques described in the next section.
ing light, the fovea s being stimulated in a manner
recommended by Bangerter. Because the position of
Practical Pleoptic Techniques the fovea has been tagged, al I the techniques
Two practical pleoptic techniques can be used for described n the section on Al transfer can be effec-
in-office or for home training in patients with tively carried out. I n this case, however, there s the
steady or fairly steady EF. The mportant aspects of additional advantage of having bleached out the
the techniques, based on Cppers' method, are to eccentric point so it does not interfere with proper
bleach out the EF point, preserving the functional localizaron of targets.

Cppers Home Pleoptics (710.20)


Another easy way to crate a direct Al and use
Cppers' methods for in-office or home training n
cases of steady or nearly steady EF was described
by Priestley et al.74 We recommend the following
materials: (1) a 100-watt frosted lamp; (2) a 2-
cm>round, black disk cut from electrical tape
and
ChapteMO 309

b. 40 mm

frosted

L f -------- black black red


fixation fixation
disc
spot spot
light
bulb
MITT

FIGURE 10-19Use of a black disk


taped on a frosted floodlight for home
training in cases of eccentric fixation.
a. Angle e is first determined by means
of Haidinger brush (H.B.) testing. b. The
disk s used to protect the fovea while
the extrafoveal rea, ncluding point e,
b dazzled. The ambiyopic eye must fix-
ate n a direction opposite to the HB
but by an amount equal to the magni-
tude of angle e. (f = fovea; MITT = Mac-
ular Integrity Tester-Trainer; O.D. =
ocultis dexter.)

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

b. Accuracy and speed of fxation: Mrs. Z set Binocular Training


up five objects on a table. Using only the After 2 months of monocular training and nearly
tagged amblyopic eye, she fixated each target full-time patching, visual acuity had improved to
in turn as rapidly as she could and counted the 20/80 by Snellen and S-chart. There was approxi-
number of objects fixated with'm a 1-minute mately 2A of nasal, unsteady EF, but the fovea was
interval. At least seven 1-minute intervals were included in the unsteadiness. Direct total occlu-
assigned each day at home, but she would usu- sion was reduced to 6 hours per day, and the
ally complete many more than the required emphasis of the training shifted to breaking sup-
minimum. The number of objects with'm 1 pression and building sensory and motor fusin,
minute increased slowly over the first month of although monocular exercises still were included
training. She noted that the fixations were in the program. The initial emphasis during the
becoming more accurate; initially many sac- binocular phase was to break suppression, then to
cades were needed to align the Al with each build suppression-free vergence ranges. Binocular
target, but later the eye moved quickly to the accommodative techniques were introduced to
target without intervening stops. intgrate accommodative and vergence skills. Ste-
2. Foveal tag and fast pointing: The transferred Al reopsis awareness and discrimination were
was used as a foveal tag for home training. After emphasized near the end of the program to com-
about a month of training, the patient could per- plete the binocular phase. Specific binocular tech-
ceive the HB with the amblyopic eye, and this was niques included the following:
used also for office training. Mrs. Z initially reported
that she had to look off to the side to place the tag 1. Antisuppressionpolarizad TV trainer, polar
on the target, which seemed unnatural. She fre- izad reading bar, string and beads, Vectograms,
quently past-pointed, but after nearly 5 weeks of Tranaglyphs, and cheiroscopic drawings: For
training, it seem natural to align the Al on a target, example, the TV trainer was particularly effective
and pointing was usually accurate. and well accepted by the patient. Initially, she
would have to sit approximately 1 m from the tele
3. Marsden ball training with and without Al visin set to hold both images in perception for
transfer: Smooth tracking, accommodation facility, 80% of the time. When the amblyopic eye's image
eye-hand coordination, and accurate fxation all would fade, she would blink or lean forward
were emphasized at various times. As Mrs. Z's skills toward the set to renew the image, then make a
increased, amplitude and speed were increased and conscious effort to hold the image for as long as
orientations besides horizontal and vertical swings possible. When 100% success occurred at a partic
were introduced. By 2 months, the patient could ular distance, Mrs. Z would move back approxi
track with good accuracy on large-amplitude diago- mately 50 cm and start the process again. When
nals and rotations for intervals of 3 minutes. she was successful from across the room, prisms
4. Hart Charts fxation and accommodative were introduced to stress her vergence, and she
jumps: This was the last technique to be introduced again started at a cise viewing distance. She liked
during the monocular phase of the training. Acuity to watch news and used the TV trainer for 30 min
and fixation skills had improved with the amblyopic utes each day.
eye. Suprathreshold and threshold letters were used 2. Convergence and divergenceVectograms,
to build fixation accuracy, saccadic speed, and eccentric circles, red-green circles, lose prisms,
accommodative facility of the amblyopic eye. For and binocular flippers: For example, the Chicago
example, for accommodative rock training, a Hart Skyline, Vectogram 7, was used for home training
Chart was place at a distance at which the letters for step-vergences in both directions. The skyline
were just readable, and a nearpoint chart was used was placed at 3A base-in so the airplane would be
at a distance at which the letters could be resolved. at 3 A base-out. This amplitude was within the
Initially, an Al was used to tag the location of the fusiona! capacity of the patient. She was instructed
amblyopic fovea. The patient slowly and alternately to altrnate her fixation and fuse each target in
fixated letters on the two cards and timed herself for turn, noting the suppression clues, and to time her
one line of letters. More lines were added as speed self for 20 cycles. She was to increase her speed of
increased. As acuity increased, more demanding fusin to a mximum level, then to increase the
distances were introduced. prism demand by 1A in both directions. She
Chapter10 317

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

NPC 6 cm; recovery 9 cm Cover test: Case 2: Anisometropic and


Unilateral at 6 m: no movement Altrnate at 6 Strabismic Amblyopia Abstract
m: 1A exophoria Unilateral at 40 cm: no A 6-year-old girl presented with anisometropia,
movement Altrnate at 20 cm: 2A exophoria esotropa, and amblyopia.79 This case report out-
Stereopsis: 70 seconds of are (Stereo Fly test) lines the diagnostic and management principies
Retinoscopy: OD: +0.75 that were employed to remedate the patient's
OS:+4 .25 -0 .50x180 Subjective (dry): OD: visual deficiencies. (We thank Dr. Garth N. Chris-
+0.75 DS, 20/20 OS:+4.00-0.25x175 20/40 tensen for permission to publish this case report.)
(Snellen full chart and S-chart) Phorometry:
Phoria at far: 1A exo, base-out 9/ Case History
16/9, base-inx/6/3 Phoria at
KB, aged 6 years, was referred by an optometrist
near: 3A exo, base-out
who diagnosed her condition as esotropa and
15/23/10, base-in 16/20/12
amblyopia. She presented with no subjectve
Negative relative accommoda-
symptoms, and her parents reported that they had
tion: +2.00 D Positive
not "really noticed" the eye turn until the referring
relative accommodation:
optometrist pointed it out. There was no history of
-1.75 D
birth or developmental problems. The child was
Amplitude of accommodation: OD, 7 D; OS, 7 D
reported to be n good health and was not takng
Visuoscopy and Haidinger brush testing: steady
any medication. Additionally, the parents reported
central fixation OD and OS
that KB had not received any previous treatment
for her eye conditon.
As regards subjective responses, Mrs. Z was enthu-
siastic regarding the improvement n her visin in the
Diagnostic Findings
left eye, which she now considered to be quite
usable. The increase in depth perception was also Unaided VA at 6 m:
much appreciated. She felt that the effort and incon- OD 20/20; OS 20/200
venience of the therapy program was worth the Dry retinoscopy:
advantages of almost normal binocular visin. OD +3.50 DS; OS +5.00 DS
Dry subjective:
Disposition OD +1.25 DS, 20/20; OS +4.50 DS, 20/200
Wet retinoscopy:
The 20/40 acuity appeared to be stable. No fur-
OD +4.00 20/20; OS +6.00
ther improvement was expected, and Mrs. Z was
20/60 Snellen; 20/68
placed on a maintenance program. She read with
Flom psychometric S-chart acuity
a polarized reading bar 30 minutes per day. She
was rescheduled for a progress check n 1 month. Cover test: constant, comitant, unilateral, left
At that progress check, there was no change n esotropa of 20A at 6 m and 40 cm (without lenses)
her visual status, and she continued to be pleased Pursuits (4+ scale): OD 4+; OS 2+ Saccades
with the results. She was asked to continu to use (4+ scale): OD 4+; OS 2+ Visuoscopy:
the reading bar approximately twice weekly for OD: central steady fixation OS:
the next 3 months, at which time another progress central unsteady fixation
check was completed. As a regular maintenance Correspondence testing:
and monitoring program, Mrs. Z agreed to use the Bagolini: suggests harmonious ARC Hering-
reading bar once weekly indefinitely. If she Bielschowsky: unreliable results Major
noticed suppression or reduced resolution of the amblyoscope: suggests NRC; angle H = 20A
left eye, she was nstructed to return for testing. base-out and angle S = 20A base-out Sensory
She was seen again in 6 months and, because fusin:
there was no deterioration in acuity or visual Rendeer test: 150 seconds of are Amblyoscope:
skills, she was then placed on a yearly recall suppression with second-degree targets Worth
schedule. dottest: unreliable results
Chapter10 319

Diagnosis dot-to-dot number drawings, smaller directionality


The diagnosis was modrate amblyopia n the left Cs, and other visual discrimination techniques
eye due to anisometropic hyperopia and accom- were used during this phase of therapy.
modative esotropa. Sensory and motor fusin training began with
the third office visit training session (2 weeks later).
Management and Results Gross fusin, antisuppression, and vergence ther-
The initial spectacle prescription was OD +3.00 apy were nitiated using the Brock string and
DS and OS +5.00 DS. The patient was nstructed to beads, Quoits Vectogram, and a cheiroscope. By
wear the lenses full-time and return to the clinic 2 the end of the fifth therapy visit, KB was found to
weeks after the lenses were dispensed. The parents have best corrected VA OS of 20/40 (Snellen 6 m)
were advised that a combination of prescription and 20/45 by S-chart. The cover test revealed a
lenses, patching, and visin training would be nec- constant left esotropa of approximately 7A at far
essary to attempt to correct the visual deficiencies. and esophoria of 2A at near. Central suppresson at
The prognosis was presented as fair to good, pro- far was found by the Worth dot test, but grade-A
vided that compliance with patching and home fusin was noted at near. No signficant change in
therapy was maintained. Estimated treatment time refractive error was found on dry retnoscopy.
was approximately 25 weekly office visits. Patching instructions remaned the same as
After 2 weeks of wearing spectacles, the visual before during the middle phase of training (office
acuity was OD 20/2Q-1, OS 20/6Q-2 (S-chart: 207 vists 6-15). Monocular accommodative therapy
68). The strabismus had substantially improved to a using the Hart Chart was nitiated to emphasize
constant, unilateral, left esotropa of 8A at 6 m and awareness of the process of focusing and relaxing
an intermittent, left esotropa of 6A at 40 cm. When the eye. After 3 weeks, KB could demnstrate vol-
the patient fused at near, stereopsis measured 45 untary ability to clear and purposefully blur near
seconds of are. The Worth dot test ndicated cen- targets with either the right or left eye. At that
tral suppression of the left eye at far but normal point, 1.50 flipper lenses were introduced for
sensory fusin at near. accommodative facility training. Concurrently
After this first follow-up vsit, a program of with accommodative rock, vergence training con-
patching and home visin training was nitiated. tinued with Vectograms and Brock string and
For patching, frosted tape was placed over the far beads. With the Vectograms, awareness of SILO
portion of the right lens. The patient's teacher was (small in, large out) was taught. Home training
informed, and arrangements were made for KB to involved the use of the cheiroscope and other
sit in the front row. The tape was positioned so that techniques to work on monocular fixation in a bin-
binocular visin could be attained for nearpoint ocular field. By the fifteenth office visit, the patient
activities. In addition, complete patching of the had best corrected acuity of 20/30 n the left eye.
right eye with an opaque occluder was prescribed The cover test revealed a small left esotropic
for home therapy, one-half hour per day. During "flick" at far with low esophoria at 40 cm. Stereop-
this time, the patient was provided with eye-hand sis had improved to 30 seconds of are on the Rein-
coordination activities such as tracing, directional- deer test (lateral, linear disparities) but 500
ity Cs, Une counting, puzzles, squirt gun and bub- seconds on Randot patterns. Again, dry refraction
bles, toothpick and grapes, gross saccades with a ndicated no change n the lens prescription.
flashlight, and flashlight chase pursuits. During the final 10 office visits, the training
During the first office visin training visit, addi- goals were to break the remaining suppression at
tional eye-hand coordination and gross pursuit and far and to introduce high-level vergence tech-
saccadic techniques were used (e.g., rotating Peg- niques at near. New techniques included present-
Board, Groffman visual tracings, four-corner sac- ing central targets in the amblyoscope and the AN
cades, and the Wayne Saccadic Fixator). At the and Dvorine cards (Keystone; see Appendix J) on a
second week of office visin training, and at Biopter (Brewster stereoscope) with double point-
approximately 2-week intervals thereafter, an S- ing. High-level vergence training ncluded jump
chart examination was performed. The S-chart acu- vergences in the open environment, fusin training
ity at this time had improved to 20/45. As a result, with Vectograms, and Keystone "Lifesaver" cards
techniques with higher visual discrimination (red-green fusin circles). Also during this phase,
demands were employed. Hart Chart saccades, binocular accommodative therapy with a bar
320 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.
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Am Optom Assoc. 1987;58:959-960.
activities were performed. Vergence training and 10. Schoenleber DB, Crouch ER. Bilateral hypermetropic
antisuppression home techniques included the amblyopia. J Pediatr Ophthalmol Strabismus. 1987;24:
Lifesaver cards, the E series of Biopter cards, and 75-77.
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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.
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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.
mal fusiona! vergence ranges 16. Mintz-Hittner HA, Fernandez KM. Successful amblyopia
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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23. Ludlam WM. Orthoptic treatment of Strabismus: a study
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41. Ron A, Nawratzki I. Penalization treatment of amblyopia: Am Orthopt J. 1970;20:39-45.
a follow-up study of two years n older children. J Pedatr 62. Callahan WP, Berry D. The valu of visual stimulation
Ophthalmol Strabismus. 1982; 19:137-139. during constant and direct occiusion. Am Orthopt J.
42. Repka MX, Ray JM. The efficacy of optical and pharmaco- 1968;18:73-74.
logical penalization. Ophthalmology. 1993;100:769-773. 63. Kirschen DA, Flom MC. Visual acuity at different retinal
43. Paris V. An alternative treatment for amblyopic Strabismus: loci of eccentrically fixating functional amblyopes. Am J
optical penalization. Bull Soc Belge Ophtalmol. 2000; Optom Physiol Opt. 1978;55:144-150.
276:31-40. 64. Bahill AT, Adler D, Stark L. Most naturally occurring
44. France TD, France LW. Optical penalization can improve human saccades have magnitudes of 15 degrees or less.
visin after occiusion treatment. JAAPOS. 1999;3:341-343. Invest Ophthalmol. 1975; 14:468-469.
45. Chatzistefenou Kl, Mills MD. The role of drug treatment n 65. Ciuffreda KJ, Kenyon RV. Accommodative Vergence and
children with Strabismus and amblyopia. Pediatr Drugs. Accommodation in Normal, Amblyopes, and Strabismics.
2000;2:91-100. In: Vergence Eye Movements: Basic and Clinical Aspects.
46. PorciattiV, Schiavi C, Benedetti P, etal. Cytidine-5'-diphos- Schor CM, Ciuffreda KJ, eds. Boston: Butterworth; 1983:
phocholine improves visual acuity, contrast sensitivity and 101-173.
visually evoked potentials of amblyopic subjects. Curr Eye 66. Kirschen DG, Kendall JH, Riesen KS. An evaluation of the
Res. 1998;17:141-148. accommodative response in amblyopic eyes. Am J
47. Gottlob I, Wizov SS, Reinecke RD. Visual acuities and Optom Physiol Opt. 1981 ;58:597-601.
scotomas after 3 weeks' levodopa administration in adult 67. Bailey I. Night Vision: Current Research and Future Direc-
amblyopia. Graefes Arch Clin Exp Ophthalmol. 1995; tions. NAS-NRC Committee on Vision monograph. Wash
233:407-413. ington, D.C.: National Academy Press; 1987.
48. Mohn K, Khanker V, Sarma A. Visual acuities after 68. Caloroso E. After-image transfer: a therapeutic procedure
levodopa administration in amblyopia. J Pedatr Ophthal for amblyopia. Am J Optom Arch Am Acad Optom.
mol Strabismus. 2001 ;38:62-67. 1972;49:65-69.
49. Leguire LE, Rogers GL, Walson PD, et al. Occiusion and 69. Farrall D. After-image transfer in the treatment of amblyo
levodopa-carbidopa treatment for childhood amblyopia. pia. Ophthalmic Optician. 1978;18:352-354.
J AAPOS. 1998;2:257-264. 70. McCormick BJ. After-image transfer therapy in non-strabis-
50. Procianoy E, Fuchs FD, Procianoy L, Procianoy F. The mic amblyopia. Ophthalmic Optician. 1978;18:641-643.
effect of increasing doses of levodopa on children with 71. Wick B. Anomalous after-image transfer: an analysis and
strabismic amblyopia. J AAPOS. 1999;3:337-340. suggested method of elimination. Am J Optom Physiol
51. Brinker WR, Katz SL. A new and practica! treatment of Opt. 1974;51:862-871.
eccentric fixation. Am J Ophthalmol. 1963;55:1033- 72. Baldwin WR. Pleoptics: historical developments and
1035. overview of the literature. Am J Optom Arch Am Acad
52. Binder HF, Engel D, Ede ML, Loon L. The red filter treat Optom. 1963;39:149-162.
ment of eccentric fixation. Am Orthopt J. 1963;13:64- 73. Meyer A. Observations on squint therapy in Switzerland.
69. BrOrthoptJ. 1952;9:89-93.
chapter n / Anomalous Correspondence Therapy

Therapy Precautions 323 Binocular Luster Training (T11.8) 336


Sensory and Motor Therapy Afterimages at the
Approaches 324 Occlusion CentratioPoint(T11.9) 337
Procedures 325 Constan! Total Other Combinations 337
Occlusion 325 Binasal Occlusion Prism-Rack Afterimage Technique
325 Graded Occlusion Method (Til.10) 338 Haidinger
of Revell 326 Optical Therapy 327 Brush Technique
Prism Overcorrection 327 Ludlam's (T11.11) 338
Method 328 Major Amblyoscope Bagolini Lens Technique (T11.12) 339
328 Classic Amblyoscopic Techniques Exotropia and Anomalous Retina!
329 Flashing Targets at the Objective Angle Correspondence 340
(T11.1) 329 Macular Massage (T11.2) Theoretical Considerations 340
331 Vertical Displacement of Targets Gross Convergence for
(T11.3) 331 Altrnate Fixation (T11.4) Exotropia with Anomalous Retinal
331 Entoptic Tags (T11.5) 332 Open Correspondence (T11.13) 340
Space Training with Surgical Results in Cases of Anomalous
an Amblyoscope (T11.6) 333 Retinal Correspondence 341 Case
Divergence Technique for Esotropa Management 342 Case Examples
(Flom Swing) (T11.7) 333 343 Case 1: Prism Overcorrection
Training in the Open Environment 336 in Esotropa 343 Case 2: Stimulating
Covariation in Constant
Exotropia 344
Case 3: Flom Swing Technique for a Small-
Angle Esotropic Patient 344

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

FIGURE 11-2Cutting mem-


brane prism (Fresnel) for appl ca-
tin to a spectacle lens. (Courtesy
of Bernell Corp.)

ORTIGAL THERAPY Fleming et al.15 recommended overcorrecting the


patient's strabismic deviation by approximately 15A
Prism overcorrection of the deviation and Ludlam's
to disrupt the ARC and, possibly, to elicit NRC. For
method are consistent with the sensory adaptation
example, a patient with 15A constant esotropa at far
theory of ARC. These procedures work best with
and near would be given 30 A base-out Fresnel
younger patients and attempt to disrupt ARC local-
prisms. With the prisms in place, the patient may be
ization while stimulating a latent NRC localization
thought of as having "sensory" exotropia. Because
system.
prism adaptation is expected, the patient's deviation
should be checked weekly. Supplemental Fresnel
Prism Overcorrection prisms can be added, f necessary, to maintain sen-
Several practitioners recommend using prism sory exotropia or, preferably, to induce exophoria.
overcorrection in the treatment of ARC. 3-14"17 Fresnel prisms can be easily removed and reapplied
(Figure 11 -2 shows the shaping of a Fresnel mem- for this purpose. Some patients experience diplopia
brane prism for appl catin to the back surface of and asthenopic symptoms. Indeed, diplopia is desir-
a spectacle lens.) This approach is most effective able, for treatment purposes, because t may stimu-
with patients younger than 16 years. The idea s late a normal fusin response. If symptoms are
to disrupt ARC adaptation by inducing diplopia. intolerable, however, constant occlusion can be
In some cases when diplopia occurs, the latent prescribed, nterspersed with short periods of prism
NRC localization manifests itself. The great wearing. Caloroso and Rouse3 recommended wear-
advantage of this method, if it is successful, is ng overcorrecting prisms only 30 minutes to 1 hour
that little of the doctor's time and limited patient per day. We suggest trying a more vigorous
effort are required. The major disadvantage is approach by prescribing constant wear of the prism
cosmetic acceptance. To an observer, the strabis- or wear for as long each day as the patient will
mus appears to be a larger deviation than was accept. In this way, NRC localization is more likely
apparent before prism application. Also, some to develop quickly.
patients cannot tolrate diplopia during the initial When ARC s disrupted and eliminated by this
stage of therapy. method after a few weeks or months of constant
applied. When NRC is repeatedly found on the can be reapplied many times. In this manner, the
Bielschowsky Al test, the ideal prism power equals angle of deviation never stabilizes, which tends to
the objective angle of deviation (15 A base-out break down the ARC localizaron. However, we have
prism, n our example). The patient should experi- reservations about how well patients, even young
ence sensory orthophoria, and fusional vergence ones, acceptthis aggressive optical approach. Rather,
training may proceed. The prism power can slowly we generally prefer simply to prescribe prism over-
be reduced over time as the patient develops correction prior to office visits for binocular training.
fusional control of the deviation. Both home and In some cases, ARC may be eliminated completely
in-office training techniques can be given to by optical means but, in many cases, other visin
strengthen sensory and motor fusin ski lis. If the therapy approaches, including training or surgery, are
deviation is too large for the patient to develop also necessary.
comfortable fusional control, extraocular surgery
probably s required.
Amigo16 and Arruga17 recommended very strong
prism overcorrection. These researchers suggested MAJOR AMBLYOSCOPE
that the prism amount be two and a half to three According to the sensory adaptation theory, there
times the magnitude of the objective angle of devi- s less chance of ARC responses when testing is
ation to keep the deviation from running ahead of conducted n a reduced (i.e., less natural) environ-
the power of the prism through prism adaptation. ment as opposed to the open (i.e., more natural)
Fresnel prisms would usual ly be placed before both environment. This observation offers support for
eyes. The very large amount of prism overcorrec- beginning ARC training in closed-space Instru-
tion s necessary in cases in which there is a large ments. Although many nstruments and devices
magnitude of prism adaptation (see Case 1). After can be used, the major amblyoscope is the best
"sensory exophoria" has been established for 1 or 2 single instrument for this purpose. Normal binocu-
months, the prism power may be gradual ly reduced lar localizaron s trained first in a controlled visual
to equal the objective angle of deviation, assuming environment using a variety of techniques, and
NRC is present. Again, if the strabismus s large, then the learned visual skills are transferred into
surgery is necessary. open space.
The amblyoscope was originally designed a cen-
tury ago by Claud Worth, primarily for the orthoptic
Ludlam's Method treatment of strabismus.19 Amblyoscopic techniques
Ludlam18 suggested a randomized approach for dis- for attacking ARC and promoting NRC that have
ruption of ARC by optical means, sometimes called evolved over the years have come to be known as
the rockum sockum method. He stated that a stable, the classic method of ARC treatment Classic tech-
full correction of hyperopia is not advisable n cases niques attempt to elicit bifoveal NRC localizaron
of esotropa with ARC, as this may allow ARC to by stimulating the latent NRC system. Amblyo-
become more embedded. With undercorrection of scopic targets are directed to the fovea of each eye
hyperopia, the angle of deviation would necessarily and are flashed to stimulate NRC. The length of time
be more variable because of the accommodative that a patient has had strabismus of early onset s a
convergence. Whether the full refractive correction key element in the depth of ARC adaptation. Like-
is worn, Ludlam18 contended that various combina- wise, a key element in rehabilitating NRC is the
tions of lenses or prisms should be worn during the amount of time involved in bifoveal stimulation.
ntervals between office training visits. For instance, Most of the amblyoscopic techniques represent vari-
one day the patient might wear a 20 A base-out ations on the theme of intensive bifoveal stimula-
prism over the left eye, the next day a 20A base-in tion. When the patient is not being treated with the
prism, then a 20A base-up prism, and so on. Fresnel amblyoscope, one eye is constantly patched or the
prisms are ideal for this purpose. Also, various patient wears prisms or lenses designed to disrupt
lenses may be used (e.g., a minus-lens add over one ARC. Classic methods are also applcable for the
eye one day and over the other eye on the following constant exotrope with ARC.
day). The same sort of randomized wearing of plus- There are numerous combinations of techniques
lens adds can be applied. involving real images, Haidinger brushes (HBs), and
Chapter11 329

TABLE11-1. Training Techniques with the TABLE 11-2. Clinical Characteristics Favorable for
Mayor Amblyoscope Classic Techniques for Treating Anomalous Retinal
Correspondence (ARC)

Flashing of targets at angle H (T11.1)


Micular massage (T 1,2) Patient's age should be between 4 and 10 years.
Vertical dlsplacement (T11.3) Younger children have difficulty cooperating, and
Altrnate f ixation (T11,4) older patients tend to have deeply embedded ARC.
Use of entoptic tags (T11,5) The later the onset of the strabismus and ARC, the
Oprv-space training with an amblyoscope (T11.6) better is the likelthood of success with classic treat-
Divergente technque(T11.7) ment techniques. Infantile esotropic individuis
have had insufficient developmental time to estab-
lish normal binocularity.
Ais. Synoptophores (see Appendix J for manufac- With full optical correction, the strabismus should
a
be greater than 20 , because ARC seems to be lss
turer nformation for products given n this chapter),
embedded in larger angles of deviation.
as well as other modern major amblyoscopes, are
Esotropa should be constant and comitant. Inter-
equipped with attachments to make tnese auxiliary
mttent cases usually do not require classic tech
techniques possible. Table 11-1 lists amblyoscopic
niques. Noncomitant deviations may have a poor
techniques discussed later n this chapter. We have prognosis regardless of ARC or NRC.
no rigid sequence of training when dealing with Visual acuity should be 20/40 (6/12) or better. Gopd
ARC; however, it s best to begin with conditions in acuity is necessary for good binocularity.
which an NRC response can be elicited. Some tech- The patient should have harmonious ARC in the
niques are limited by the patient's immaturity, poor open environment, because there is a chance of
cooperation, or lack of perceptual awareness. The causing intractable diplopia f unharmonious ARC is
doctor may, therefore, be limited to using the sim- present. (Check for harmonious ARC with Bagolini
pler methods and must begin training with these. lenses.)
The patient should demnstrate NRC on at teast
some testing procedures. This finding suggests that
Qassic Amblyoscopic Techniques
the ARC adaptation may not be deeply embedded.
Strabismic ARC patients who respond favorably to
dassic techniques on the major amblyoscope have NRC = normal retinal correspondence.

certa i n clinical characteristics (Table 11-2). They


tend to be young childrenfrom a functional
standpoint, the younger the better. However, most classic techniques on an amblyoscope, it s com-
children younger than 4 years are ncapable of mon for ARC therapy to take between 3 and 6
cooperatmg with amblyoscopic methods. Further- months of concentrated effort by doctor and patient.
nore, the later the onset of the strabismus, the bet-
tET. The adaptation theory implies that NRC Flashing Targets at the
localization may be stronger and easier to revive in Objective Angle (T11.1)
hte-onset cases. A favorable age of strabismus The first classic training technique usually
onset is 1 year or, preferably, much later. Also, the attempted is superimposition of two dissimilar tar-
ition theory suggests that the larger the angle |f gets (first-degree targets) at the objective angle of
deviation (moderately, but not extremely, large) , ; deviation. Illumination of the amblyoscopic targets
less embedded is the ARC localization. In addi-, (e.g., a circle and a star) s ncreased to the mxi-
patients should have good acuity n each eye, ancy, mum while the room illumination is dimmed. The
and HARC. Patients who vary from automatic flashing unit is set to a rapid altrnate
recommendations can be accepted for treat-but flash. Because the patient has ARC and the foveas
the prognos is will be worse and the are being stimulated, the two targets will not appear
lent more complex. to be in the same visual direction. The images will
Ideally, an intensive training program consists of be separated by an amount equal to the angle of
: three 1-hour office visits per week, supple- anomaly (angle A) (Figure 11 -3, percept 1). This per-
by home training and occlusion. Using cept s considered to be ARC projection.
330 Chapter11

Throughout this rehabilitation process, the patient


should be encouraged to use mental effort in an
-O attempt to see the ghost image, at least part of the
time. Depending on how embedded ARC s, the
treatment time to achieve consistent NRC responses
on the amblyoscope can vary widely from a few
weeks to several months with 3-5 hours of in-office
training each week.
It s important to note that some patients do not
experience binocular triplopia when targets are
flashed at the objective angle of deviation.3 There
can be an abrupt shift in correspondence from
IT^" ^ anomalous to normal, although the triplopia may be
1 ^^~~~~- point a perceived fleetingly by some patients. The patient
1
1 starts to report that the two targets are seen in the
1 HARC same visual direction and that they do not appear
1
1 _J
separated as previously. On occasion, one target
NRC
may appear to move suddenly to reach the position
of the other, even though the amblyoscope tubes
Percepts: remain locked at the objective angle of deviation.
1. Strong ARC with no NRC O 4 Such responses indcate that NRC localization is
2. Strong ARC with weak NRC @ 4
being revived.
Types of flashing other than rapid altrnate
3. Weak ARC with strong NRC <.
flashing can also be used to stimulate NRC local-
4. No ARC with strong NRC ization. Unilateral flashing of the nondominant
eye at the objective angle is one variation. Stimu-
FIGURE 11 -3Flashing targets at the objective angles (TU .1). The dual- lation may be varied from slow to rapid, and the
ity of correspondence is shown in stages of visin training. (ARC = anom-
alous retinal correspondence; f = fovea; HARC = harmonious anomalous
light and dark phases can be modified to promote
retinal correspondence; NRC = normal retinal correspondence.) superimposition. The goal, in this case, s to have
the patient superimpose the circle and the star (or
similar first-degree targets) at the objective angle
Over time, the bifoveal stimulation revives the when flashing is stopped and the two targets are
latent NRC localization system. When this occurs, seen simultaneousiy. During simultaneous flash-
the patient will notice a faint ghostlike image (star) ing, the patient can also look for NRC localiza-
from the nondominant eye appearing in the center tion of both images and try to maintain NRC
of the dominant eye's image (circle) (see Figure superimposition during the moments after flash-
11-3, percept 2). This percept is called binocular ing is discontinued.
triplopia. The dominant eye sees one image while This rehabilitation process requires merely that
the nondominant eye sees two under binocular the patient continu looking in the instrument
conditions. At this point, there is a duality of local- while the foveas are stimulated. The time required
ization systems, both ARC and NRC. This percept to reach binocular triplopia may extend from only
of binocular triplopia represents an intermediate one session of training to many. Some patients
stage in the rehabilitation process. never achieve this stage, but most will succeed n
With reinforcement, the clarity of the poorly 10 to 20 sessions. Because patients may become
defined ghost image (the NRC image of the star), bored with the therapy, the therapist should have a
and the vividness of the peripheral image (ARC large number of appropriate major amblyoscope
localization of the star) fades (see Figure 11-3, per- slides for variety. Another good first-degree slide
cept 3). The training process under these stimulus pair for the early stage of training is the soldier and
conditions is complete when the patient is aware the sentry box (see Figure 5-6). Initially, peripheral
of only the NRC projection. The star will appear first-degree targets are introduced, but later central
inside the circle only when both foveas are simul- first-degree and all sizes of second-degree targets
taneousiy stimulated (see Figure 11 -3, percept 4). (having suppression controls) are also used. Suc-
Chapter11 331

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

EntopticTags(T11.5) the patient achieves this, a ring is introduced to the


Consistent with the adaptation theory of ARC is the right eye. The patient now tries to superimpose the
observation that NRC is present if there are no con- dot and ring while maintaning an Al cross that is
tours in the visual field, as NRC is innate. This phe- centered on the superimposed targets. ARC local-
nomenon can provide a starting point in treatment ization is indicated when the Ais seprate, forming
of ARC in the open environment, which is filled an uneven cross. The targets should be removed,
with complex contours. Most major amblyoscopes NRC should be re-established with blank fields,
come supplied with slides and flash units that can and then contoured targets can be reintroduced.
genrate Ais. Slides S3, a horizontal streak, and S4, As NRC localization is achieved, more complex
a vertical streak, are used in the Synoptophore. targets are introduced, and the training process is
Each has a central red fixation mark. As with the repeated.
Hering-Bielschowsky test (see Chapter 5), it is cus- An ARC response is indicated if the Al cross
tomary to flash the dominant eye first with the hor- comes apart (Figure 11-4a). The doctor should be
izontal streak and then to flash the nondominant aware that ARC may be present even when there is
eye with the vertical streak. With the older instru- a perfect cross (see Figure 11 -4b). This percept may
ments, the opal diffusing screen should be occur because the Al is unnatural enough to show
removed from the optical pathway when each eye NRC but the real targets may induce ARC at the
is flashed, providing a much stronger Al than very same moment (see Figure 11-4c). The goal is
would otherwise be generated. Most new instru- to achieve superimposition of the Ais and the real
ments have an Al mode with intensified illumina- targets (see Figure 11-4d). The doctor must be cau-
tion, so that removal of the diffusing screen is tious when interpreting the patient's subjective
unnecessary. The background illumination in the reports and must not assume falsely that there is an
Synoptophore is kept low enough so that the Ais NRC response for the real targets. It is possible that
are not washed out. The Ais are sustained by an the strabismic deviation has changed during the
automatic background flashing feature of the training session in the amblyoscope: The patient
instrument. The timing of light and dark phases and may be superimposing the real targets at his or her
the speed of flashing can be adjusted conveniently subjective angle. The douse target test can verify
as des i red. whether the patient is superimposing at angle S.
Positive Ais are considered less natural than nega- Many Synoptophores come equipped with
tive; therefore, NRC is more likely to be elicited attachments to produce HBs for each eye. An HB
when positive Ais are seen. To see these, long dark may be for the left eye, the right eye, or for each
phases should be emphasized initially. If the patient eye binocularly. Patients with ARC frequently are
can see a perfect cross with the positive Ais, the dark unable to superimpose two real images, but they
phase can be shortened, and the negative Al can be may be able to superimpose less natural targets
made visible more of the time. It is not unusual for such as two HB images. This technique requires
the patient to report seeing a cross (NRC) in the dark central fixation by each eye. The tubes of the Syn-
phase but a noncross (ARC) in the light phase. In optophore should be locked at the objective angle.
such a case, various adjustments of the automatic One HB should be rotating clockwise and the
flashing unit may help in developing a cross response other counterclockwise, so superimposition can be
with negative Ais. The goal is for the patient to monitored. Superimposition is indicated when the
achieve a perfect cross while both eyes are being HBs appear to be together, with a fluttering and
flashed simultaneously, indicating NRC. flapping of the composite image.
Once NRC with Ais can be achieved, real HBs are more easily seen if the Synoptophore
images may be incorporated into the training. The targets are printed in black and white on transpar-
traditional slides used initially in this technique are ent film. Colored slides tend to wash out the
a ring and a dot. The amblyoscope arms are adj usted images of the HBs. (Clement Clarke offers several
to the angle of deviation, al I targets are removed, black and white slides: F161 and 162, F163 and
and the Ais are properly applied. The patient must 164, and F165 and 166.) Similar slides also may be
see a perfect cross of the Ais. In the case of left custom-made for use in the Synoptophore.
esotropa, a dot is presented to the left eye as the The following description suggests a training
patient tries to continu seeing a perfect cross, sequence using combinations of entoptic tags and
which would indcate that NRC is maintained. If real targets set at the objective angle of strabismus.
Chapter 11 333

attempts to superimpose the HB and the Al. Flash-


ing the nstrument lights, either manually or by
various settings of the automatic unit, may help the
patient to achieve superimposition. When this s
accomplished, a real target (dot, circle, square, or
any suitable line drawing on a clear sude) is placed
n the tube, and the nondominant eye fixates on t.
If superimposition of this combination can be
maintained, another real target is presented to the
dominant eye. Ideally, superimposition of the two
real images should occur, in conjunction with the
superimposed HB and the vertical Al. (This tech-
nique requires central fixation in each eye.) These
foveal tags are excellent monitors of the state of
correspondence. Many different combinations are
possible. It is good to try a number of combina-
tions on each patient, because some might be very
effective n helping the patient to break ARC,
whereas others may be much less effective.
O
Open-Space Training with an
Amblyoscope (T11.6)
Although the major amblyoscope is good for train-
ing in a reduced environment, the fact remains that
the conditions of seeing n such an nstrument are
very different from those of habitual, everyday see-
ing. Some patients have difficulty transferring the
visual skills achieved in the amblyoscope to the
open environment. Some modern amblyoscopes
come equipped with Stanworth mirrors. 19 When
these mirrors are flipped nto position, the patient
can superimpose ordinary amblyoscope targets as
CURE 11-4Esotropa of the left eye with anomalous retinal corre-
(ARC) with the amblyoscope set at angle H. a. Noncross i
f the targets were n open space. The patient looks
horizontal afterimage seen by the right eye and the vertical through the half-silvered mirrors at a distant blank
after-by the left eye. b. A normal retinal correspondence wall while simultaneously seeing the targets in
(NRC) may occur because of the relative unnaturalness of
the after-s. c. Real targets (dot and ring) are seen
each tube of the amblyoscope. This modification
separated, indicating ~or more natural targets but NRC for allows for the treatment of ARC under more natural
less natural targets (afterim-i. d. Goal n training is superimposition conditions than could otherwise be accomplished
of real targets and afterim-L Caution n interpretation is
required f the setting of the cope is at angle 5 rather than
using a standard amblyoscope. All the previously
angle H. described classic methods can be applied now n a
relatively natural environment.

have the nondominant eye perceive an HB. i, Divergente Technique for


introduce a real target to the dominant eye. Esotropa (Flom Swing) (T11.7)
the patient superimpose them. A blue filter II Drs. Merton Flom and Cordn Heath devised a diver-
insertable lens that comes with the Synopto-') gence technique on the amblyoscope (also known as
befare the dominant eye is used to equalize the Flom swing technique) for treatment of small-
light ntensities, so that the HB can be seen by angle esotropa with ARC.20 The technique s based
nondominant eye under binocular conditions. on Morgan's motor theory of ARC. Morgan6 held that
patient has trouble superimposing these tar- fusional vergence eye movements can stimulate cova-
the real target is removed and a vertical Al is riation between ARC and NRC n some strabismic
ited on the dominant eye. The patient then
334 Chapter11

TABLE11-3. Qualifcatin Gritera for the


Divergence Technique (Flom Swing Technique)

Patients should be teenagers or adults, because the


technique requires intense concentration and tofer-
ance of dlscomfort.
Esotropa with full optical correctlon should be 20*
or less, because this amount approaches the lim'rt of
fusiona! divergente that can be trained at far,
Esotropa should be comtant and the visual acuities
20/40 (6/12) or better.
The patent should nave harmonious ARC in the
open environment; otherwise, there is a chance of
causing intractable diplopia. (Gheek for harmonious
ARC with Bagolini tenses.)
The patient should demnstrate the abitity to f use
the targets placed at the subjective angle in the
amblyoscope, to maintain visin of the suppression
controls, and to perceive at least some peripheral
stereopsis.

ARC = anotnalous retinal cwwspondence.

patients. When the eyes are in the strabismic posi-


tion, ARC exists, but when the patient makes a
fusional vergence eye movement and straightens the
eyes, covariation resulte in NRC. The essence of the
divergence technique with the amblyoscope for
small-angle esotropes is to establish ARC fusin at the
subjective angle and then slowly to diverge the eyes
through the angle of deviation, using fusional diver-
gence demands, until the eyes are physically straight.
The patient then is taken out of the instrument while
O O
concentrating on holding the eyes straight in the
ortho position. It is hoped that the patient will covary
to NRC in open space as the eyes are straight. If he or FIGURE 11-5Flom swing technique (T11.7). a. Esotropa of the left
she does covary, the patient temporarily becomes eye with anomalous retinal correspondence (ARC) in the major
nonstrabismic, shows NRC localization, and experi- amblyoscope. The instrument s set for angle 5. b. Sufficient base-in
demand s introduced to crate sufficient divergence so that angle S
ences a dramatic awareness of stereopsis in the open becomes exo and angle H becomes zero. ARC remains, because
environment. One of the virtues of the divergence superimposition s with points a and f(fovea). c. Ratient views objects
technique is that if it is going to work with a patient, it n the open environment, attempting normal retinal correspondence
while the eyes are held in the ortho position. (NRC = normal retinal
works relatively quickly. The training program takes
correspondence.)
only a few weeks instead of the months necessary for
classic methods.
Only certain esotropic patients qualify for the discomfort, Patients should have an angle of devia-
divergence technique. Table 11-3 lists the qualifi- tion of 20A or less. We have found this magnitude
cation criteria we recommend. Besides having to be the approximate training limit for divergence.
comitant deviations, good acuity, and HARC, Patients who match this clinical profile have the
patients should be older (teenagers or adults) best chance for functional cure of strabismus.
because the technique requires much concen- The divergence technique proceeds as follows
trated effort and usually is associated with visual (Figure 11 -5): After the patient's angles H and 5 have
Chapter11 335

been measured, a pair of peripheral, third-degree


fusin slides are placed in the major amblyoscope at
the patient's angle S. The swing slides are fre-quently
used targets for this technique (Figure 11 -6).
Background room illumination should be dim. The
automatic flashing unit is set for altrnate flashing at a
rapid rate of 2-3 cycles per second. Under these
stimulus conditions, the patient should have a vivid >'
percept of the fused swing targets, with perception of
a stereoscopic effect and affirenss. of suppression
controls (i.e., both flowers) n view. At this point
FIGURE 11-6Major ambiyopic si des for
there s ARC fusin, although not true fusin. O the Flom swing technique
Starting at angle S, the targets are diverged at a or- 0 (T11.7).
mal ratjo test the patient's divergence limit (.e., the
breakpoint). After reroyer the targets are again
diverged but this time very slowly (approximately 2A he or she looks above the instrument and should
per minute) while the patient maintains a percept of a note whether there s a rapid shift back to the eso-
single mage with suppression clu'es afa^tereop-sis. tropic position. If the eyes appear to be straight,
Patients usually experience eyestram a<T they diverge patients who still experience eyestrain in the open
their eyes. This sensatio of eyestrain is important and environment should be allowed to reinforce align-
can be used as part of the technique., The patient s ment for a few minutes before a cover test is done
encojjraeed to experience the stressful J:o verify that the eyes are indeed aligned. The
~ -------------------- >^0~" Q-a'A ctes&qrcjW'rTp -~- cover test s, of course, dissociative and the patient
feelmg of divergmg the eyes, as unpjeasant as this may not be able to regain fusin afterward. If the
may be. When diplopia or suppression occurs, the patient lapses back into the esotropa, the preced-
divergence demand is decreased until fusin is re,-^ ng steps should be repeated until the patent can
establishedthat s, the fusional vergence recvery. reflexly fuse in the open environment and hold the
Altrnate rapid flashing contines at the recvery eyes n alignment for relatively long periods.
point for severa 'minutes to reinforce s'ensory and Successful treatment may take 10 or more nten-
motor fusin; then divergence s again increased sive office visits along with home training. Ideally,
very slowly. This rgimen contines until mximum office visits for amblyoscopic training can be sched-
divergence can be held. The eyes should be^ uled two or three times per week to achieve rapid
diverged maximally n a series of breaks and recov-' progress in achieving covariation. We recommend
,eries for a period of approxmatefy~2TTminutes. The; constant patching out of the office, except for a half-
; c goal is to straighten the eyes physically. In other hour daily home training session during which diver-
"wrds, the magnitude of fusional divergence eye gence is practiced using a Bernell Mirror Stereo-
movement is equaUo the magnitude of angle H. scope. Caloroso and Rouse3 recommended using
When .aJlgnmeJTt^'' s accpmplished , jrictthe other home training nstruments to build the patient's
amblyoscope, the patient^atternpts^to hpld align- range of "anomalous divergence" n the open envi-
ment in the open environment. If, however, align- ronment (e.g., Brewster stereoscopes, Vectograms).
ment of the eyes s not acheved after approximately Patients who achieve a functional cure of strabismus
20 minutes of divergence training, the patient s and become esophoric should be given retainer exer-
taken out of the instrument for a much-needed cises to prevent regression. We recommend 15 min-
rest. If divergence s accomplished, the room illu- utes of divergence training once weekly indefinitely
mination is slowly raised and the patient is using a Minivectogram at near distances. Progress
nstructed to concntrate on keeping the feeling of visits are scheduled at 3-month ntervals for the first
eyestrain. On many occasions when the patient year to determine whether the retainer exercise
meets the fusional divergence demand in the open schedule s sufficient to control the deviation.
environment, he or she experiences NRC fusin Using the divergence technique, Grisham's21 suc-
with vivid stereopsis. The patient looks at real cess rate for a functional cure of small-angle esotro-
objects across the room and appreciates depth, pa with ARC s approximately 33%. Wick 22
perhaps for the first time in his or her life. The ther- reported a remarkable 56% cure rate (9 of 16) for
apist should closely observe the patient's eyes as these patients n a prvate practice setting. These
336 Chapter11

training be conducted almost exclusively in free


TABLE11-4. Open-Environment Techniques for space. In many respects, training techniques in
Anomalous Retinal Correspondence (Usually open space at the centration point are similar to
Esotropa) those performed in the Synoptophore, as both
foveas are stimulated simultaneously. Administer-
ing many of the open-space techniques, however,
Binocular luster training (Ludlam's rnethod) (T11.8)
Afterimages at the centration point (T11.9) is difficult in all but the most cooperative patients.
Prism-rack afterimage technique {T11.10) Nevertheless, successful results are sometimes
Hatdinger brush technique fT11.11) obtained, and using various open-space tech-
Bagolini lenstechnique (TU.12) niques may result in a reduction in the number of
Gross convergence for exotropia wth anomalous treatment sessions.
retinal correspondente (T11.13)
Techniques of open-environment training can use
binocular luster, Ais, HBs, a prism bar (rack), Bagolini
tenses, real objects, or combinations of these (Table
cured patients have straight eyes all or nearly all day 11-4). These techniques usually are applied at the
and markedly increased stereopsis, but they may centration point in cases of esotropa, with the cen-
need to wear prisms for esophoria. If these patients tration point add in place. They can also be used in
do happen to lapse back into an esotropa (e.g., cases of constant exotropia with ARC, provided that a
after a long workday), they do not usual ly see dou- centration point can be achieved with minus adds
ble, because they also covary back to ARC. and the gross convergence technique (T11.13)
Although approximately one-third achieve a func- described later in this chapter.
tional cure, another one-third of our patients who
complete 10 training sessions end up with a micro-
esotropia that is smaller than the original deviation
Binocular Luster Training (T11.8)
and usually demnstrate some stereopsis. We Ludlam18 advocated a binocular luster technique
believe these cases are partial cures. Therapy is to establish NRC. There are numerous ways to
unsuccessful in another one-third of our patients, elicit luster, but the best method in cases of ARC is
who show no change in their condition. Fortunately, to set up conditions to promote red-green color
these patients do not invest much time or money in fusin (see Figure 5-38). For home training, the
the attempt for a functional cure. patient may view a brightly illuminated, blank,
It is important to remember that the successful white wall while wearing red-green filters, but illu-
treatment of small-angle esotropa with ARC in mination should be evenly distributed without
adulthood is far from hopeless, as some authorities shadows. When the patient stands between the
in the past have believed. Cure rates between one- source of illumination and the viewing screen, this
third and one-half are acceptable for a therapeutc condition is difficult to meet. For this reason, a ret-
intervention that avoids surgery and does not roilluminated gray screen is preferable for in-office
involve a great deal of training time. In geographic training.
locations where binocular visin specialists offer The esotropic patient with ARC may be better
this service, we strongly recommend that patients able to appreciate luster if plus lenses are used and
who qualify for the divergence technique be a blank screen is placed at the patient's centration
informed that this option exists and be referred for point. Under these conditions, it is hoped the
treatment. patient will be able to see red-green fusin (luster)
over the entire screen, as there are no contours in
the field. The perception of form with sharp con-
tours is thought to be the triggering mechanism for
TRAINING IN THE the ARC split-field response. If, however, the
OPEN ENVIRONMENT patient reports seeing a split red-green field, usu-
Although ARC training in cases of esotropa can be ally no further attempt is made for training because
performed in the open environment, we believe it of the poor prognosis indicated by such a
is generally a good rule to break ARC using the response. Seeing the Swann split-field effect in a
major amblyoscope before free-space techniques contourless field indicates a deeply embedded
are introduced. Some practitioners prefer that ARC response (see Figure 5-39).
Chapter11 337

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

FIGURE 11-7Method of direct


attack at the objective angle in space.
a. Cross afterimage (Al) on pend tip
(probable normal retinal correspon-
dence [NRC]). b. Noncross afterim-
age on pencil tip (anomalous retinal
correspondence [ARC]). c. Bagolini
streaks superimposed on light, but
with noncross afterimage (harmoni-
ous ARC). d. Superimposition of
Bagolini streaks, lights, and cross
afterimage (NRC if no eye movement
on unilateral covertest). (O.D. = ocu-
lus dexter; O.S. = oculus sinister.)

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

fovea of the deviating eye and no longer on point Theoretical Considerations


a. This causes the patient with HARC to report see- Exotropia is generally much easier to cure, regard-
ing lights below the intersection of the streaks (see less of the state of correspondence. The prognosis
Figure 11-8b). Because the fovea of the deviating is better because the age of onset tends to be later
eye usually is suppressed, only one light s seen n for exotropia than for esotropa, and thus the re-edu-
most of these cases (see Figure 11 -8c). Rapidly cation of fusin s easier. Normal fusin had the
introducing and removing the prism may be suffi- opportunity to develop early in many of these patients,
cient in disrupting ARC, and an underlying NRC before the onset of strabismus. More mportantly, most
may emerge as a result of extensive training of this exotropias are intermittent (as compared with
nature. The patient should then see the light cen- esotropa, which tends to be constant); ARC is also
tered in the cross, which indicates NRC, provided intermittent because of covariaton. When the eyes
that the strabismic angle is fully compensated by are straght, the patent s fusing with NRC. Covari-
prism (see Figure 11-8d). ation is consistent with Morgan's motor theory of
Another variation of this technique is to stimu- ARC and seems to be independent of the magni-
late diplopia in open space (without a compen- tude of exotropia. Training to elimnate ARC in
sating horizontal prism). Spontaneous diplopia is exotropia is, therefore, a form of motor fusin
not easily seen in free space by a patient who s training. Consequently, sensory training specifi-
strabismic; therefore, the environment may have cally for eliminating ARC can usually be bypassed
to be less than natural at times. For this purpose, in exotropes, with the exception of some cases of
graded occluders, lowered room illumination, constant exotropia.
vertical dissociating prisms, and bright fixation
targets may be helpful. For example, a bar of
graded filters (either gray or red) is useful for elic- Gross Convergente for Exotropia
iting an NRC response with the Bagolini lens pro- with Anomalous Retinal
cedure. The attenuators are placed over the Correspondence (T11.13)
dominant eye and progressively increased until Gross convergence training involves the use of
the patient reports diplopia of the light, which push-up targets, minus adds, and Ais. This tech-
indicates possible NRC localization. Once NRC nique is helpful primarily in cases of constant
diplopia is appreciated, it should be extended to exotropia but can also be used n cases of intermit-
all distances and fields of gaze using antisuppres- tent exotropia with a remote nearpoint of conver-
sion techniques of flashing, blinking, increasing gence. The essence of the technique is to give the
stimulus contrast, and focusing the patient's atten- patient as much feedback as possible to help him
tion (see Chapter 12). The patient is not left or her make a gross convergence movement, ulti-
diplopic at this point in strabismus therapy; sen- mately to achieve bifoveal fixation and sensory
sory and motor fusin should be expanded maxi- fusin on a nearpoint target using fusional conver-
mally using methods described in Chapters 13 gence. Gross convergence should be attempted
and 14. Any residual angle of deviation may need with all exotropes as part of the initial treatment
to be compensated with prisms, lenses, or sur- sequence.
gery. On the other hand, if a patient does not The first step in gross convergence training,
show the ability to fuse the diplopic images pro- assuming the refractive error is corrected, is to build
duced with these techniques, training should be the patient's awareness of the eyes in motion. This
discontinued immediately. Intractable diplopia is training develops a tactile-kinesthetic sense of con-
an undesirable outcome. vergence. Initially, the patient can simply practice
moving the eyes in all directions of gaze while
increasing his or her awareness of sensation associ-
ated with these movements. The sensation probably
EXOTROPIA AND ANOMALOUS
arises from the eyelid margins, extraocular muscles,
RETINAL CORRESPONDENCE and orbital tissue. Monocular saccades can also be
Even though more than 50% of exotropic patients stimulated with various prism powers so that the
have ARC, this condition is less influential in the patient can learn to sense subtle eye movements.
prognosis for a functional cure of exotropia than it is Large accommodative shifts should be made, far to
in the prognosis for esotropa, for various reasons. near to far, under binocular conditions. The patient
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.
In the evenings, Ms. B would lose fusional control of REFERENCES
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2. Flom MC. The empirical longitudinal horopter in anoma- 21. Grisham JD. Treatment of Binocular Dysfunctions. In:
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117-118,162-163,209,213. dence: efficacy of therapy. Am ] Optom Physiol Opt.
4. von Noorden GK. Binocular Vision and Ocular Motility. 1987;64:405^H 0.
Theory and Management of Strabsmus, 5th ed. St. Louis: 23. Hugonnier R, Hugonnier S, Troutman S. Strabismus, Het~
Mosby; 1996:255. erophoria, Ocular Motor Paralysis. St. Louis: Mosby;
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8. Cook D. Considering the ocular motor system in the treat- 26. Herzau V. How useful is anomalous correspondence?
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Assoc. 1984;55:109-117. 27. Hugonnier R. The Influence of the Operative Overcorrec
9. Kerr KE. Anomalous correspondencethe cause or con- tion of an Esotropa on Abnormal Retinal Correspon
sequence of strabismus? Optom Vis Sci. 1998;75:17-22. dence. In: International Strabismus Symposium. Arruga A,
10. Folk ER. Treatment of Strabismus. Springfield, lll.: Charles ed. New York: Karger; 1968:307-310.
C.Thomas; 1965:72. 28. Katsumi O, Tanaka Y, Uemura Y. Anomalous retinal corre
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12. Revell MJ. Anomalous retinal correspondence: a refrac- 29. de Decker W. Result of Surgery Versus Prism Tolerated
tive treatment. Ophthalmic Optician. 1971 ;2:110-112. Overcorrecton Therapy of Anomalous Correspondence.
13. Bagolini B. Sensorial anomalies in strabismus (suppres- In: Proceedings of the Second Congress of the Interna
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thalmol. 1976;41:1-22. Marseilles, Fr.: Diffusion Genrale de Lbrame; 1976:
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Treatment of Deviation in Comitant Squint. In: Proceedings 30. Jampolsky A. The Post-Operatve Use of Prisms. In: Pro
of the First Congress of the International Strabismological ceedings ofthe Second Congress ofthe International Stra
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
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17. Arruga A. The Use of Space Diagnostic Methods and of 33. Christenson GN. Treatment of esotropa with anomalous
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18. Ludlam WM. Lecture at San Jos Vision Training Seminar, Anomalies. In: Pediatric Optometry. Rosenbloom AA,
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19. Revell, MJ. Strabismus: A History of Orthoptic Tech- 223.
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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

Occlusion Antisuppression Therapy 348 Major Amblyoscope (T12.2) 355


General Approach to Antisuppression Illumination Gradient and Flashing 355
Training 348 Chasing 355
Antisuppression Variables 349 Endpoint Suppression 356
Attention 349 Brightness 349 Target Penlight and Filters (T12.3) 356
Contrast 349 Color 349 Target Size Hand-Mirror Superimposition
350 Intermittent Stimuli 350 Target (T12.4) 357 Cheiroscopic
Movenient 351 Tactile and Kinesthetic Carnes (T12.5) 357
Senses 351 Auditory Sense 351 Counting 358
Combinations 352 Four-Step Coloring and Drawing 358
Approach to Antisuppression Training Point-to-Point Chasing 358
353 Step One 353 Step Two 353 Tracing 358
Step Three 353 Step Four 353 Modified Remy Separator (T12.6) 359
Specific Antisuppression Techniques 354 Brock String and Beads (T12.7) 359
Translid Binocular Interaction Trainer Televisin Trainers (T12.8) 361 Pola-
(T12.1) 354 Mirror (T12.9) 362 ReadingBars (T12.10)
362 Management Considerations 363 Case
Example 364 Problem 364 Clinical Data
364 Management 364 Results 365

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. O.S. O.D.

o.s. O.D.

target has little training valu. Similarly, if a control


FIGURE 12-1Example of the use of target brightness to break sup- is suppressed most of the time, the task may be too
pression of the left eye. a. Actual target. b. Patient's perception. c. Tar-
demanding, thereby frustrating the patient.
get of the left eye lluminated with a penlight. d. Patient's perception
where suppression s broken. Note that room illumination should be In cases of strabismus with deep suppression,
lowered so that the dominan! eye sees a target with low luminance. large superimposition targets (first-degree targets)
(O.D. = oculus dexter; O.S. = oculus sinister.) are presented initially in an amblyoscope (see Fig-
ure 12-2). Smaller targets are gradually introduced
as the suppression zone shrinks as a result of ther-
pressing eye. This s particularly applicable to first- apy. Rapid progress often occurs at first, because it
degree targets such as are shown n Figure 12-2: is much easier to treat peripheral than central sup-
The circle can be brightiy colored, and the X might pression. Progress slows as the fovea is approached.
be black. Fat fusin (second-degree) and stereopsis targets
are introduced later as suppression is broken, to
Target Size build both sensory and motor fusin skills.
Target size and the size of suppression controls In cases of heterophoria, fovea-sized suppres-
should be tailored to the size of a given patient's sion controls should be selected. As fusional ver-
suppression zone in a particular instrument. (Refer gence ranges are stressed as part of motor fusin
to Table 5-1 for zone classification and dimen- training, endpoint suppression must be detected
sions.) The choice of appropriate target size usually and broken. The goal is to develop normal or
proceeds on a trial-and-error basis. Also, the dis- above-normal ranges of fusional convergence and
tance of a target from the patient determines its divergence that are free of foveal suppression.
size according to the inverse square relationship. A
target size or distance s chosen so that the patient Intermittent Stimuli
can hold the suppression controls n perception Flashing a target or an eye s very effective in
most (approximately 80%) of the time, not al I the breaking down suppression. The visual system
time. If the patient s successful all the time, the responds vigorously to any rapidly changing stimu-
Chapter12 351

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

sensory fusin is discovered to be an unrealistic


TABLE12-3. Antisuppression Techniques objective (e.g., in cases of horror fusionis, large
aniseikonia, lack of fusin potential), antisuppres-
sion therapy should be stopped immediately
TI 2,1 Translid Binocular Interaction Trainer
before intractable diplopia ensues.
T12.2 Major amblyoscope
T12.3 Penlight and filters
T12.4 Hand-mirror superimposition Translid Binocular Interaction
T12.5 Cheiroscopic games Trainer (T12.1)
T12.6 Modified Remy Separator 67
Alien ' introduced the Translid Binocular Interaction
T12.7 Brock string and beads
Trainer (TBI), which provides strong intermittent
T12.8 Televisin trainers
photic stimulation. The battery-powered instrument
T12.9 Pola-Mirror
consists of a pair of small, transparent lightbulbs that
T12.10 Reading bars
are alternately flashed for each eye. The flashing is
accomplished by a free-running multivibrator at a
environmental condition, a more demanding rate of approximately 7-10 Hz, which approxi-
instrument or environment is chosen for the mates the alpha rhythm. The bulbs are separated
patient. The progression is also toward more natu- by a distance equal to the patient's interpupillary
ral viewing conditions. With each new technique, distance; they are placed gently against the closed
the training process (steps 1-4) is repeated until the upper eyelids so that they barely touch the skin
patient has eliminated suppression under all envi- (Figure 12-4a). Ideally, a protective shield should
ronmental conditions and instruments, including be placed between the exposed bulb and the eye-
the open environment. lid to prevent the possibility of eye injury in case of
breakage of a bulb. The lights flash alternately so
that impulses arrive at the visual cortex asynchro-
nously. Each pulse has a duration of approximately
SPECIFIC ANTISUPPRESSION one-fortieth of a second. This rate of altrnate
TECHNIQUES flashing is believed to make suppression impossi-
Most visin therapy instruments and targets contain ble. Flashing contines for a 10-minute period as
suppression controls, because suppression is an the patient experiences pulsating light patterns
omnipresent consideration in binocular visin seen through the eyelids. This technique appears to
remediation. For purposes of this discussion, we be effective in preparing a patient to break through
have selected only those techniques that we have a suppression response using other instruments,
found to be the most effective and practica! in a with the eyes open (see Figure 12-4b).
direct assault on pathologic suppression. A list of ten Physiologic diplopia training (see Figure 12-4c)
specific antisuppression techniques is presented in and chiastopic fusin training (see Figure 12-4d) can
Table 12-3. These techniques are loosely organized also be used. We recommend such flashing light-
from those appropriate for deep peripheral suppres- bulbs as can attach to spectacle frames or to instru-
sion to those for shallow foveal suppression. This ment fusin targets. Such flashing provides a strong
sequence is based on our experience with patients. antisuppression stimulus that can be used for home
Extreme unnatural visual conditions are neces- training purposes. The therapist can place each light
sary when attempting to break deep suppression. over each target (e.g., in a Brewster stereoscope, Ber-
The suppressing eye must be bombarded with rela- nell Mirror Stereoscope, or Aperture-RuleTrainer).
tively bright, large, flash i ng, and moving targets or The TBI and other rhythmic flashing units
controls to break the suppression response. As sup- should not be used for patients having a history of
pression is broken, the clinician must be vigilantto epileptic seizures. Grand mal or petit mal sei -
ensure that sensory fusin occurs or is possible and zures may occur in a small portion of the popula-
that unresolvable diplopia is not generated. The tion when viewing a flashing light source. Closing
clinician should ensure that normal retinal corre - the eyes and having the light go through the eye-
spondence is present and that normal sensory lids, however, supposedly reduces the likelihood
fusin is possible before these techniques can be of this type of reaction. Because of the possibility
effectively applied. If, during the course of therapy, of seizures, treatment time should always be short
Chapter12 355

/<T*T>
TT

CURE 12-4Translid Binoc-


ttf Interaction Trainer for
dkemate flashing at the alpha
. a. Light source placed on
eyelid. b. Lights n front of
opened fes. c. Physiologic
diplopia amng. d. Chiastopic
fusin with bulbs at 40 cm
variable vergence demands
:ed by changing of tar-
separation distance.

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

movements to gain sensory fusin. As previously,


TABLE12-4. Varations on Antisuppression central fusin targets and suppression controls are
Training with a Penlight and FHters (T72.3) used as peripheral suppression decreases.

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

tapproaches the suppression zone, suppression


iv occur, at which point the patient blinks and e
prism s jiggled to re-establish diplopia. The
ppocess contines until the two images are joined
i one and color fusin occurs. The prism should
horizontal (f there s no vertical deviation) [hen
this happens.
This technique might be described as "macular
ssage" to break suppression. Background illu-
ination can be slowly raised as the patient prac-
Jfces this technique, working toward a natural
Iwsual environment. At some point, the filters are
'moved and the process repeated. The prism
amount can also be reduced n small ncrements,
A
or 2 steps. This modificaron requires the i
patient to supply the necessary fusional vergence
to join the diplopic mages when they reach the
horizontal meridian. With this technique, diplopia
toining can be transformed into a sensory and
FIGURE 12-5Example of hand-held mirror
motor fusin training method. superimposition training. (f = fovea.)

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

Blinking s usually helpful. The clinician needs to


be mindful that many strabismic patients can
cheat and draw fairly good pictures by alternately
looking at each eye's field. As the patient suc-
ceeds n breaking suppression, the therapist
selects targets with more detall and finer lines.
Parents can find cartoons or comic strips of inter-
est to their child and mount these as targets for
cheiroscopic tracing at home.
Cheiroscopic games can be performed with
either Brewster or Wheatstone stereoscopes. The
factors of attention, brightness, target size, inter-
mittent stimuli, target movement, contrast, and
color can all be applied to break suppression.
Many stereoscopes have the additional benefit of
allowing binocular pointing (tactile-kinesthetic
sense) as an antisuppression method. The fused tar-
get s seen with the two pointers convergng to the
fixated portion (Figure 12-6).

Modified Remy Separator (T12.6)


The Remy Separator can be used for antisuppres-
sion therapy.9 This simple device consists of a
hand-held septum dividing two targets set at a
nearpoint distance. The septum can be made for
home training purposes by using a rigid material
FIGURE 12-6Double pointing for antisuppression training. a. Ratient
such as a file folder placed in the midsagittal plae pointing to homologously fused targets n a Brewster stereoscope.
n front of the patient's nose. (See Chapter 13 for a b. Patient's perception.
discussion of the Remy Separator.) In cases of stra-
bismus, two dissimilar objects or drawings can n-
tially be placed on either side of the septum. The method works well with patients who have inter-
patient attempts to fixate the two targets alternately mittent strabismus, anisometropic amblyopia, or
at a regular rhythm without suppression. The use of heterophoria. The patient holds one end of a 3-m
prism neutralization s usually necessary n cases string to the tip of his or her nose while the other
of strabismus so that superimposition can be end is held by the therapist or tied to a distant
achieved. The training goal s simultaneous per- object such as a doorknob (Figure 12-7). Direct-
ception of the two images for at least 1 minute's ing visual attention, the patient should be able to
duration. Antisuppression stimuli applicable to this see two strings apparently intersecting wherever
training environment are target size, color, differ- the horizontal components of the visual axes
ential llumination, blinking, flashing, and point- meet (Figure 12-8a). Seeing only one string or a
ing. When the patient can binocularly perceive portion of one string indicates pathologic sup-
"fovea-sized" targets such as dots, the technique pression (see Figure 12-8b). Three brightly col-
has reach its limits of first-degree fusin. Second- ored beads on the string usually serve as fixation
and third-degree targets can then be attempted. targets. When one bead s fixated and seen as sin-
(Refer to Chapter 13 for further discussion of this gle, the other two beads should be diplopic. A
technique.) double image of the string should also appear to
intersect at the fixated bead. This represents the
proper physiologic diplopic percept. Patients with
Brock String and Beads (T12.7) binocular anomalies, of course, may not see this
A popular physiologic diplopia training technique correct image. Suppression is indicated when
s Brock string and beads. This antisuppression only one image of the nonfixated beads or only
360 Chapter12

FIGURE 12-7Brock string and


beads. Training in the primary (a) and
secondary (b) positions of gaze.

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

method while mamtainmg physiologic diplopia of


the nonfixated targets as the fixated bead s moved
closer. Rotations can also be conveniently accom-
plished by moving the distal end of the string to
various positions of gaze.
A major drawback of Brock string and beads,
however, s that some patients quickly become
bored. Children often have difficulty training with
string and beads for more than 1 or 2 weeks. The
therapist should remember that physiologic diplo-
pia training does not need to be confined to the
string and beads. A physiologic diplopia control
for suppression can be introduced with many other
methods. For example, a child can watch televi-
sin or read a comic book while holding a pointer
stick or pendn front of the target. A double
image of the pointer or pencil wouid indcate
physiologic diplopia. When suppression occurs
during the course of the activity, the patient should
blink or shake the pointer to actvate the diplopc
image. As one might expect, this variaton of phys-
iologic diplopia training is much more popular
than s string and beads with some patients.
FIGURE 12-8Patient's perception of Brock string. a. Middle bead is
bifixated with images of string intersecting it. Nearest bead is seen
with heteronomous diplopia (bead on dashed line seen only by the
Televisin Trainers (T12.8) left eye). Farthest bead is seen with homonymous diplopia (bead on
Most patients can find at least 30 minutes n their dashed line seen only by the left eye and on the left side). b. Central
day during which they can watch televisin. suppression of the left eye (portion of dashed line missing).

Because training compliance usually is not a prob-


lem, the televisin trainer can be an effective anti-
suppression method for home use. The technique The televisin trainer is attached to the televi-
may be nappropriate, however, for patients with sin screen vertical ly with suction cups. The
constant strabismus or deep, extensive suppres- appropriate filters are worn by the patient over
sion, unless the strabismic patient wears a Fresnel spectacle or contact lenses, f recommended. The
prism equal to the deviation. The patient should be therapist or patient should alternately occlude
able to accomplish fusin of a televisin screen at each eye to make sure each filter mutual ly
some distance before this technique can be used. excludes part of the televisin screen. The patient
Suppressing patients having intermittent strabis- moves as cise to the televisin screen as s neces-
mus, anisometropic amblyopia, and heterophoria sary to a position at which the images can be seen
generally are good candidates for this method. without suppression. The patient should then
Televisin trainers are available in red-green and slowly step back from the screen until a viewing
polarized materials (Figure 12-9). The red-green distance is found at which there s either unilateral
models work better with young children, who tend or altrnate suppression approximately 20-30% of
to tilt their head (depolarizing the trainer images), the time. That position s the correct training dis-
and in patients with deep suppression. In contrast, tance for the patient. If the patient suppresses more
polarized models are more appropriate for adults than 30% of the time, the viewing distance may be
and patients with shallow suppression (polarized tar- too far or the trainer unit too small.
gets being more natural than red-green targets). Tele- Once the proper training distance is established,
visin trainers usually come in large and small sizes. the task is for the patient to watch a 30-mmute pro-
Selection can be made on the basis of the depth and gram while breaking suppression every time it
extent of the patient's suppression and, necessarily, occurs. Suppression s indicated when one portion
the size of the patient's televisin screen. of the trainer darkens to obscure that part of the
362 Chapter12

FIGURE 12-9Televisin trainer to


treat suppression.

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

HCURE 12-10Pola-Mirror training.

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

IF 20/25- 20/25+ 20/20 20/15-


1 20/20 20/15- 20/15 20/15
Hereopsis (Fly) test 200 140 40 50
H&Konds of are)
Bbppression Intermittent parafoveal Intermittent foveal None None
HplK All data were collected wth the patient wearng the full anisometropk spectacle lenses.

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

Diagnostic Considerations 368 Vision Vectograms and Tranaglyphs 381


Therapy Sequence for Comitant Divergence Training at Near
Esotropa 368 (T13.8) 383
Correction of Refractiva Error 368 Divergence Walk-Aways (TI 3.9) 384
Elimination of Major Sensory Pro|ected Base-ln Slides(T13.10) 385
Anomalies 368 Binocular Accommodative Rock
Compensating Prisms and Lens (T13.11) 386 Vergence Rock
Techniques (Flipper Prisms)
x
(T13.12) 386 Aperture-Rule Trainer
Additions 369 (Double Aperture)
Centration-Point Training 369 Sensory and (T13.13) 387
Motor Fusin Training 370 Changing Remy Separator (T13.14) 388
Vewing Distance 371 Surgical Orthopic Fusin (T13.15) 389
Management 372 Follow-Up Care 373 Computerized Divergence Procedures
Vision Therapy Sequence for Esophoria 373 (TI 3.16) 390
Speciflc Training Techniques 373 Case Management and Examples 391
Amblyoscopic Divergence Technique Convergence Excess Esotropa 391
(TI 3.1) 374 Bernell Mirror Management Principies 391 Case
StereoscopeBase-ln Example 392 Basic Esotropa 393
Training (T13.2) 374 Brewster Management Principies 393 Case
StereoscopeBase-ln Training Example 394
375 Divergence Insufficiency Esotropa 395
Isometric and Step Vergences Microesotropia 396 Management
(T13.3) 377 Principies 396 Case Example 396
Stereoscope Tromboning (T13.4) 377 Esophoria 397 Management Principies
Anaglyphic Fusin Carnes (TI 3.5) 379 397 Case Example 398
Brock String and BeadsBase-ln Training
(T13.6) 380
Peripheral Fusin RingsBase-ln Training at
Far(T13.7) 380

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

far and near deviations.) The use of a limited num-


TABLE13-1. Vision Therapy Sequence ber of variables, however, is convenient for classifi-
for Comitant Esotropa cation of dignoses, to avoid the hundreds of
possible permutations arising when nine variables
are considered. Nonetheless, it should be remem-
1. Full corrertion of any slgnifIcant ametropia, partic-
ularly latent hyperopia
bered that a complete strabismus diagnosis and
2. Amblyopta therapy, if needed, improving visual prognosis should include a description of all nine
acuity to at least 20/60 (6/18) variables: constancy, comitancy, laterality, direc-
3. Train'mg of bask ocular motility in each eye; fixa- tion, magnitude, AC/A ratio, variability, dominancy,
tion, saccades, pursuits, and accommodation and cosmesis (see Chapter 4). Diagnosis of hetero-
4. Anomalous retinal correspondence therapy, if phoria would exclude constancy, laterality and,
prognosis for its etimination is favorable possibly, variability and cosmesis.
5. Sensory alignment of the eyes at some or all dis-
tances using any combination of prlsms and added
tenses (assumng normal retinal correspondence)
6. Antisuppression therapy, if normal retinal corre VISION THERAPY SEQUENCE FOR
spondence present, to establish diplopia awareness COMITANT ESOTROPA
and bask sensory fusin
7. Central sensory and motor fusin training, if nor Our recommended sequence of steps in the man-
mal retinal correspondence present, to achieve agement of comitant esotropa with visin therapy
good stereopsis and mximum fusonal vergence is outlined in Table 13-1. Prospective visin ther-
ranges, f ree of suppression, at alt viewing dstances apy patients should have a reasonably good prog-
8. Strabismus surgery, if necessary, to reduce the nosis for functional cure (see Chapter 6).
angle of devation to within the range of ref lex
fusional vergence
9. Prescription of compensatory prisms and added Correction of Refractive Error
tenses as needed Optical management of eso deviations, particu-
10. Development of good monocular and binocular larly esotropa, requires full plus correction of any
efftciency sfdlls significant refractive error, based usually on a
11. Maintnance home exercises and perodic progress
cycloplegic refraction. Many cases of accommoda-
checkups
tive esotropa can be completely resolved by cor-
rection of the full amount of hyperopia. (Refer to
discussions in Chapter 7'.) The patient is encour-
optics or surgical treatment is applied without aged to wear these lenses full-time, even if visual
visin training, we have frequently observed that acuity at far is initially blurred. Children usually
the patient's level of binocular functioning remains relax the spasm of accommodation in a matter of
deficient. We hope that all options for binocular days, whereas young adults often take longer, a
treatment are given serious consideration in the few weeks, depending on the amount of latent
patient's best interests. hyperopia present. In cases of esotropa in infants
and toddlers, some doctors even overcorrect the
full hyperopia by as much as 1.00 diopter (D) in an
DIAGNOSTIC CONSIDERATIONS effort to improve alignment at near distances. Any
residual esotropa or esophoria may require com-
Eso deviations, whether tropic or phoric, are gener- pensation, at least n part, with base-out (BO)
ally classified into three categories: (1) divergence prism or plus addition lenses or both. This optical
insufficiency (DI), having a low accommodative- treatment is beneficial if there are no major sen-
convergence/accommodation (AC/A) ratio; (2) basic sory anomalies of deep amblyopia, suppression, or
eso (BE), having a normal AC/A ratio; and (3) con- anomalous retinal correspondence (ARC).
vergence excess (CE), having a high AC/A ratio.
(See Chapters 3 and 7 for discussions of these clas-
sifications.) In this scheme, however, not all nine Elimination of Major
diagnostic variables of a deviation are taken into Sensory Anomalies
account; only the near and far magnitudes are con- This discussion of visin therapy approaches in
sidered. (The AC/A ratio can be calculated from the esotropa assumes that major sensory anomalies
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

tance at which fusin can be established. He Sensory and Motor


recommended beginning training at the nearpoint, Fusin Training
where the visual axes cross in esotropa, as he
believed that this location offered the best chance The patient with an eso deviation must be senso-
for achieving good binocularity. The proper rially ready (i.e., have at least fat fusin and, pref-
amount of plus power at the centration point erably, stereopsis) before motor fusin demands
(where visual axes cross) can easily be calculated can be intioduced in visin training. This s not a
using the following formula: lens power (in diop- problem n esophoria but often s so in esotropa;
ters) = H/IPD, where H s the horizontal objective intensive therapy for elimination of ARC and sup-
angle of deviation expressed in prism diopters and pression may be requred to develop fat fusin.
the interpupillary distance (IPD) s expressed in (See the therapeutic techniques described in
centimeters. For example, suppose the esotropa s Chapters 11 and 12.) Sensory fusin usually s
15A at far and the IPD s 60 mm. The centration established after ARC and suppression are bro-
point would be 40 cm from the patent's eyes: 15/6 ken. When motor fusin training s begun, the
= 2.50 D. (Refer to Chapter 6.) monitoring of suppression is, in effect, training
The centration-pont concept can be applied to that enhances both fat fusin and stereopsis
any esotropic patient who has a constant deviation when appropriate targets are used to emphasize
at far. This is a theoretical calculation, and the these sensory fusin ski lis.
visual system does not always respond n a In addition to sensory fusin development, ocu-
mechanical and predictable manner. In some lar motility must be good. (Evaluation of saccadic
cases of esotropa, even with NRC, plus lenses and pursuit eye movements and fixation are dis-
seem to have lttle or no immedate effect. If there cussed n Chapter 2.) It s usually important to
s ARC, the add for the centraton point s usually include duction (monocular) and versin (binocu-
neffective, probably due to the influence of ver- lar) motility training before and during the early
gence adaptation to the habitual anomalous corre- part of the motor fusin training program for eso
sponding point in the deviating eye. In any case, deviations. This is particularly applicable when
an attempt to align the eyes at the centration point there is a noncomitant deviation. Even in cases of
should be made n all cases of esotropa when comitant eso deviations, one or both eyes may
visin therapy is being considered. have limited abduction, particularly in unilateral
There are several advantages to training an eso- esotropa of long standing.
tropic patent in open space as opposed to using Assuming the patient demonstrates some stere-
closed-space nstruments such as the major opsis, targets with stereopsis clues are introduced
ambiyoscope, not the least of which s the transfer as soon as possible. Various combinations of anti-
of learned sensory and motor fusin sklls to the suppression stimuli for breaking suppression and
natural visual environment. If the calculated enhancing the fusin percept may be required for
amount of the centration-point add does not com- the patient with constant esotropa. These tech-
pletely neutralize the deviation, the clinician niques may include flashing, large target sze,
should try an add with higher power while plac- brightness, movement, and the like (see Chapter
ing the fixation target at the appropriate closer 12). Foveal suppression should be monitored fre-
fixation distance. It s hoped that a nearpoint dis- quently and, f found, should be broken immed-
tance can be found at which the patient has the ately. Eliminatng foveal suppression promotes
opportunity for bifoveal fixation under these con- development of motor fusin ranges. As soon as
ditions. The next step would be to establish sen- sensory fusin s steady and consistent for a par-
sory fusin at the centration point by breaking ticular pair of targets, a vergence demand for the
suppression (e.g., using Brock string and beads) patent should be introduced. If, for example,
(T13.6). Vision training for fusional divergence angle H is 15A eso on the major ambiyoscope, the
can also start at this position. Several nstruments tubes are moved slowly from the 15 A BO setting
and techniques can be used effectively with cen- to a 20 A BO setting. Training fusional conver-
tration-point adds as high as +5.00 Dfor exam- gence initially bulds the patient's confdence. If
ple, Vectograms and Tranaglyphs (T13.8) in the patient s able to converge 5A, the tubes are
conjunction with flipper prisms for step vergence reset at 15A BO, and then a relative 5A base-in (Bl)
demands(T13.12). demand s ntroduced. (This means that the set-
Chapter13 371

ting on the nstrument scale actually reads 10A


0O.) Other instruments, such as the Dual Pola- TABLE13-2. Methods for Changing
chrome Illuminated Trainer (see Appendix J for Vergence Demand
rformation on each trade product cited n this
diapter), may also be used in this manner. Diver-
A, Prisms
gence training s repeated until the patient's
-1." Rlsley prisms
fusin range, with clear visin, increases beyond 2. Lose prisms
the ortho demand setting on the instrument scale. 3. Prsrn bar
This goal, however, is not always achievable at a. Conventional gtass or plstic
this early time in visin therapy.
b, Wck's Fresnel bar
Accommodative changes will blur the fused
image; blur ndicates that pur fusional vergences 1. Use of septums {septa}
are not in play. When the target (e.g., Vectogram) 1, Brewster stereoscope (h0mofogous point separa
tion increased for ir and dcreased for 8O
becomes blurred, the patient s relying on accom-
demands}
modative vergence changes (decreasing accom-
2, Wheatstone stereoscope (mirror angle changed
modative response, in an eso case) to maintain
for il or BO demands}
single visin. The goal at this point n therapy s to
3, Remy Separator (Bl demand increased with tar
achieve clear visin with mximum fusional get separation inerease)
ranges, free of foveal suppression, around the
C Vectographk and coiored filters (separation varied
angle of deviation.
ior prismatic demands)
Most patients with esotropa are ready to leave
instrument training and begin open environment D. Plus and minus spherkal lenses
training when the motor fusin range at the angle 1. BO demand witlt plus
of deviation s 10A in either direction. However, 2, Bl demand with minus
if preventable, the patient should not be allowed E. Chiastopic and orthopic fusin
to lapse into strabismus. The patient should be 1. 8O demand with chiastopic fusin
kept fusing most of the time by means of com- 2. Bl demand with orttiopic fusin
pensating prisms or plus-lens additions. During F. Changing fixation distance
visin training, whether in- or out-of-office, ver- 1. Insde instruments (e.g,, Brewster stereoscope, Bl
gence demands are introduced n the open envi- demand from far to near and BO demand from
ronment (free space). Numerous methods are near to far}
available for changing vergence demand, some 2. In open envtronment (e.g., Bagotini lenses used
of which are listed inTable 13-2. with penlight push-ups and push-aways)
Sliding vergences can be introduced with con- Bl - base-n; BO = base-oul
venient and available mirror stereoscopes, split
Vectograms, Tranaglyphs, and the like. Such tech-
niques simlate the smoothness of movement
place. The important rule s that the demand must
afforded by a major amblyoscope. Sliding ver-
be within the patient's ability. As the motor fusin
gence ranges are trained initially because they are
range expands, the difference between Bl and BO
generally easier to achieve than are step vergence
demands can be increased. The range s eventually
responses. Step vergences are introduced later,
expanded to include an adequate Bl range. An
beginning with small prismatic demands and
ideal goal is to have a Bl range that is twice the
allowing ampie time for the patient's responses.
magnitude of the eso deviation, while clear visin
Rapid step changes in vergence demand are con-
s maintained (Sheard's criterion).
veniently accomplished with the use of a prism
bar. Wick7 described a bar made with Fresnel
Press-On prisms that has the advantage of less Changing Viewing Distance
weight and bulkiness than conventional prism bars One principie of open-environment training for
made of glass or plstic. Flipper prisms are also strabismus is that such training should be started
good for step vergence training. BO prism may at a distance at which the patient can fuse (or
nave to be used exclusively at first, until the patient when fusin can be established with prisms and
can learn to fuse when Bl prism is flipped into lenses). Eventually, the patient works toward
372 Chapter13

In cases of CE with a high AC/A ratio, the eso


TABLE13-3. Common Surgical deviation increases with decreasing viewing dis-
Proced/res for Esotropa tance. Push-ups with a bifixated target are effective
in training for fusional divergence. This is because
the patient must use fusional divergence to main-
Divergence insuff iciency esotropa
tain bifixation while absolute convergence is
Strengthen both lateral rectus muscles with a
bilateral resection procedure, which decreases
increasing at near. (Refer to Figure 3-19, which
deviation at far primarity illustrates graphically the relation between the
Convergence excess esotropa ortho demand une and the AC/A une.) This coun-
Weaken both medial rectus rnuscles with a bilat terintuitive concept of push-up training in these
eral recession, which decreases deviation at near cases of eso deviation becomes rational when the
prima rily relation between the demand line and the AC/A
Can be comb'med with Faden procedure (e.g., ratio is considered.
suturing a medial rectus muscle to the sclera 11-
15 mm posterior to its insertion)
Basic esotropa
A unilateral or bilateral recession and resection
Surgical Management
operation, depending on the size of the deviation Extraocular muscle surgery is necessary in cases
or of esotropa in which the magnitude of the devia-
A bilateral medial rectus recession operation, tion is too large for compensating prisms to be
weakening both medial rectus muscles worn with acceptance by the patient. As regards
Immediate postoperative goal prognosis for functional cure, an esotropa is
10* undercorrection to ortho position considered large if the magnitude exceeds 20 A
(see Chapter 4). A common surgical procedure is
bilateral medial rectus recession (Table 13-3),
which not only reduces the magnitude of the
those distances at which fusin is deficient. The angle of esotropa but also tends to lower the
D\ and BE esotropic patient is encouraged to AC/A ratio. A lowered AC/A is particularly help-
Vowi^' n to fu ^7k at H h \ centrationpointandthe " u\ \n cases o CE. The symmetric operation
fiiQ-^nT? backwarcl while maintainmg (medial rectus of each eye) helps in maintainine
tusion. The power of the training add (e g trial cornitancy, in contrast to recession and resection
case lenses) should be reduced accordingly so ot the muscle of one eye only. In cases of DI sur-
that the patient's visin is not blurred as viewing geons often prefer a bilateral lateral rectus resec-
distance is increased. In cases of DI, t is easy to tion, as this symmetric operation tends to preserve
visualize how a receding target requires an comitancy and increase the AC/A ratio. Two
mcreasmgly greater demand on fusional diver- types of operations are popular with strabismus
gence. This occurs because the eso deviation surgeons for basic esotropa: bilateral medial rec-
enlarges when viewing s changed from near to tus recession or unilateral recession-resection
tar (see discussion in Chapter 3). Even in BE (Strengthening and weakening approaches n sur-
cases, the receding target s more difficult to fuse gery are dscussed n Chapter 6, as are other
at tar than at near fixation distances; stereopsis aspects of surgical management.)
diminishes with ncreasing distance, and stereopsis At the beginning of a visin therapy program for
is a strong stimulus for maintaining fusional esotropa, the doctor should introduce the patient
divergence. Other factors at near also help an to the possibility that extraocular muscle surgery
individual to maintain alignment of the eyes The wil be necessary. If the deviation remains cosmeti-
relatively larger retinal images at near provide cally obvious after full correction of the refractive
more "glue" for sensorimotor fusin. Also tac- error, discussing this possiblity s essential for
tile-kmesthetic clues at near help the patient to good management. If the residual eso deviation at
attend to the act of fusing the target with both near and, particularly, at far measures 20A or more an
eyes. These aids to fusin are lacking at far operation often s necessary for the sake of long-term
Increasmg the fixation distance from near to far' comfortable and efficient binocular visin In our
theretore, ,s useful in several training techniques experience, fusonal divergence can be effec-tively
for both DI and BE deviations. trained, butthere are realstic limite
Chapter13 373

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.)

eye. When the patient achieves sensory fusin, Bl


demands are increased gradually (or BO demands
are decreased) as the patient attempts to maintain
fusin. This sliding (tonic) vergence training helps
to ncrease fusional divergence. The nstrument
can also be conveniently changed into a cheiro-
scope if an intensive attack on suppression is
needed; this is applicable in the presence of NRC
but notARC.
An intermedate goal is for the patient to achieve
376 Chapter13

O.C. TEIEBINOCULAR MEAD

O.C. compared with the Wheatstone nstrument led to ts


popularity for clinical use (and also for entertain-
FIGURE 13-3Schematic top view
ment purposes as a parlor stereoscope). Several
commercial varieties of the Brewster stereoscope
SEPTUM exist, but all have a similar optical design.
The schematic top view of such an nstrument
f (KeystoneTelebinocular in this example) s shown
in Figure 13-3. The Telebinocular s llustrated n
Figure 13-4. The eyepieces are +5.00 D spherical
+5.00 D lenses (which can be made from a single spherical
SPHERE lens that s cut n half, with each center placed on
opposite sides). BO prismatic effect s created by
the extreme distance between the optical centers
0-S. S = 95 mm D relative to the patient's IPD. The standard separa-
tion between optical centers is 95 mm and is des-
llustrating the optics of the Brew-ster stereoscope. (h = target
separation distance representing an ortho demand for vergence; O.C.
ignated by the letter S. Fixation distance s
= optical center; O.D. = oculus dexter; O.S. = oculus sinister; S = designated by the lowercase letter u and s 0.2 m
standard separation between optical cen-ters; u = fixation distance.) (20 cm) for farpoint testing, optical infinity for the
+5.00-D lenses. The target separation distance rep-
resenting an ortho demand for vergence is desig-
stereoscope, a septum without mirrors s used for
dissociation. BO prisms are incorporated for pur- nated by the lowercase letter h. In Figure 13-3, the
poses of ncreasing the lateral field of view n this homologous points are the star seen by the left eye
nstrument and allowing for more range n lateral and the circle seen by the right eye.
vergences. The compactness of this stereoscope as The formula to calclate h (target separation) n
millimeters is as follows:

h = S (n millimeters) x u (n meters) x dioptric


STEREOGRAM IN
lens power
ADJUSTABLE
CARO HOLDER
Therefore, h = 95 x 0.2 x 5, so h = 95 mm. This
means that when the homologous points at optical
infinity are 95 mm apart, the demand on vergence
s zero. In other words, the points are in the posi-
tion of ortho demand. For any target separation (h)
other than 95 mm, a vergence demand is created.
A rule to remember is that at a 0.2-m fixation dis-
tance (optical infinity), it takes 2 mm to equal 1 A.
AUXItlARY As an example, suppose the star and circle were
LENS-HOLDER/OCCLUDER
SLIDES separated by only 87 mm nstead of 95 mm. There
s now a difference of 8 mm, which represents 4A
BO demand. Conversely, if the h valu is 103 mm,
divergence of 4A is required to superimpose the
star and circle.
Although it s true that 95 mm is the theoretical
separation for homologous points on a stereogram
that represents an ortho demand at optical infinity,
the practica! clinical valu of h that s most often
used s 87 mm, because most people, on average,
FIGURE 13-4KeystoneTelebinocular. converge approximately 4 A when viewing n a
closed environment such as the Brewster stereo-
scope. This, in effect, compensates for the average
amount of proximal (psychic) convergence. The
SPHEROPRISM EYEPIECES IN
Chapter13 377

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

FIGURE 13-5Example of a stereogram


for step vergence training (Stereo Opti-
cal Co.).

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)

scale, the Bl demand to the patient ncreases rap-


idly, making the technique very challenging.
The isometric technique can be repeated when Near (40cm equivalen!)

progress with tromboning slows or stops. Here, the


patient simply holds sensory and motor fusin for
several minutes at a challenging divergence and
accommodative demand setting, while stimulus
conditions remain unchanged.

Anaglyphic Fusin Games (T13.5)


Anaglyphic fusin games, a sensory and motor
fusin technique designed by Grisham, s particu-
Theoretically, there is no target separation for an ortho demand at the
larly appropriate for young (2- to 6-year-old) eso-
plae of the lenses. Because the ortho distance goes from 87 mm at
tropic children. The technique (or game) is far to 63 mm at near, base-in fusional divergence is required (e.g., tar-
intended to establish a child's gross sensory and get separation of 87 mm on the stereogram) as the tromboning goes
motor fusin while he or she plays with a parent at from far to near.

home. The child's success n the game provides


feedback to the trainer about the development of
380 Chapter13

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

(Figure 13-9). In this farpoint technique, the red-


FIGURE 13-9Root Rings target.
filtered eye sees only the red rings and the
green-filtered eye sees only the green rings.
(Both colored rings are printed on a black back- Vectograms and Tranaglyphs
ground.) The patient is instructed to fixate the A set of polarized training targets printed on rigid
center configuration while wearing red-green photographic sheets (called Vectograms) helped to
spectacles (red on right eye and green on left popularize management of strabismus and hetero-
eye). The outer complementary-colored rings are phoria. These vectographic si des probably set the
laterally disparate, creating a stereoscopic effect. standard for open environment sensory and motor
The outer rings should appear to float forward n fusin training (Figure 13-11). These targets are of
relation to the central fixation rea. Even in interest to children and adults and have suppres-
cases of strabismus, if the farpoint angle is sion controls of various sizes; they provide both
smaller than 10 A, many patients can appreciate crossed and uncrossed disparity for stereopsis.
the floating of the rings. For some patients, eso- Crossed polarizing filters, oriented at 45 and 135
phoric and esotropic, several minutes of intense degrees, are worn to dissociate the images. Rela-
target viewing is required before the full stereop- tively natural seeing conditions are simulated
sis effect s perceived. Even many orthophoric when the targets are fused. Three of the Vecto-
individuis with good binocular visin may gramsAcuity Suppression, Stereo Test, and Basic
require a minute or more to perceive the mxi- Fusinare nonvariable (unsplit). The remaining
mum stereoscopic effect. The latency period of seven are variable (split) and so can be set to com-
perception, however, tends to decrease with pnsate for a patient's horizontal angle of deviation
repeated training sessions. to establish sensory and motor fusin. Fusional
A DI or BE deviation should be neutralized
with BO prism. The patient stands approximately
2 m from the target and is nstructed to maintain
the floating effect while he or she slowly walks
away, as far as possible, while maintaining fusin
of the target. As fixation distance s ncreased, the
rings should appear to be floating closer. They
may appear to be 1 or 2 m closer than the wall on
which the target is attached. This is so for the
outer rings that have the largest lateral disparity.
The smaller rings also have a dramatic floating
effect but not to the same extent as the larger
ones. Fusional divergence ranges are built up by
gradually reducing the BO compensation and,
eventually, by introducing Bl prism of progres-
sively greater power. Later, flipper prisms are used
to ncrease vergence facility at far.
Other similar anaglyphic targets for the periph-
eral fusin ring technique (T13.7) are the Bernell
FIGURE 13-10Nonvariable Tranaglyph mounted in the top portion
500 and 900 series (e.g., ring target shown mounted of a Bernell Dual Polachrome Illuminated Trainer. Example of a 500-
in the lower portion of the Dual Polachrome Illumi- series variable Tranaglyph is shown in the bottom portion. (Courtesy
nated Trainer n Figure 13-10). Stereo targets with of Bernell Corp.)
suppression controls are transparent and can be
attached to a televisin screen. An isometric tech-
nique would be to ncrease the Bl prism demand to
mximum acceptance while the patient watches
televisin for an extended period (e.g., 30 minutes).
A Bl Fresnel or lose prism can be attached to the
spectacles to crate the appropriate divergence
demand for the patient.
382 ChapteMB

a. e. h.

No. 2 Variable No. 10 Variable

b. No. 9 Non-Variable

i.

No. 5 Variable
No.3 Non-Variable
C.
No. 11 Variable

No. 6 Variable

No.4 Non-Variable
No. 12 Variable

No. 7 Variable

FIGURE 13-11Ten Vectograms for the Bernell Dual Polachrome llluminatedTrainer (previously named the Polachrome Orthopter). a. Quoits, no.
2. b. Spirangle, no. 5. c. Clown, no. 6. d. Chicago Skyline, no. 7. e. Mother Goose, no. 10. f. Figure 8, no. 3. g. Compass Points, no. 4. h. Acuity
Suppression, no. 9. i. StereoTest, no. 11. j. Basic Fusin, no. 12. Note that there are no targets 1 or 8. Vectograms 3, 4, and 9 are not split, butthe
others are, so that varying base-in and base-out demands can be nduced with the latter. (Courtesy of Bernell Corp.)
Chapter13 383

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^

FIGURE 13-12Flipper prisms for step


vergence training.

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

FIGURE 13-13Lessening divergence 3ABI


demand with increasing fixation dis-
tance when viewing a pair of Vecto-
grams. (Bl = base-n.)

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

HQJRE 13-14Double aperture septum


on the Aperture-Rule Trainer for
sin demands.

Aperture-Rule Trainer (Double


Aperture) (T13.13)
"IheVodnoy Aperture-Rule Trainer is a good instru- Ortho
nt for both office and home training. A double Point
aperture s used to crate Bl demands (Figures 13-14
and 13-15).This technique is very difficult for most
|CE and BE patients, because of a significant eso
Nieviation at near and because the aperture acts as
septum, which s dissociative. For this reason, s
nstrument usually is not introduced at the
faginning of the visin therapy program. The
it s nstructed to look at the pair of targets jgh
the double aperture. The pair of targets is at the
O position and remains there jghout the
training; the viewing distance is 40 This s actually
orthopic fusin (discussed in next section);
however, the Aperture-Rule ar has the
dissociative feature of a septum. If is difficulty
fusing the first few cards, the it is nstructed to
look above the apertures to ipointer stick placed at
the end of the rule, or far-away f necessary.
Fixation on the pointer to diverge the eyes so
that the patient can illy fuse the pair of targets
even though they appear blurred. Plus-addition
lenses can be to allow the patient to see the
fused target

Hiere are 12 pairs of targets, ncreasing n sepa-


and ranging n demand from 2.5 A Bl (card I)
to 30A Bl (card AP12). The prismatic demand FIGURE 13-15Fusional divergence demand
with two apertures.
391

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
skills in esophoric cases tend to regress more so 1. Griffin JR. Efficacy of visin therapy for nonstrabismus
than convergence skills in exophoric cases. vergence anomalies. Optom Vis Sc. 1987;64:411-414.
Good retainer exercises are the Aperture-Rule 2. Major D, Pirotte P, Griffin JR. Orthoptic Therapy with
Microcomputer: A Comparative Study. Research project.
Trainer (T13.13) and orthopic fusin (T13.15).
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.
minute period once weekly. If the patient notices 3. Vaegan. Convergence and divergence show large and
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
progress evaluation and, probably, a more rigor-
Clinical Aspects. Boston: Butterworth-Heinemann; 1991:
ous retainer program. 196-220.
5. Postar SH. Ophthalmic Prism and Extraocular Muscle
Deviations: The Effect of Wearing Compensatory Prisms
Case Example
on the Angle of Deviation n Cases of Esotropa. Snior
Surgical management is infrequently necessary research paper. On file in the M.B. Ketchum Memorial
in cases of esophoria. We have, however, seen Library, Southern California College of Optometry, Fuller
patients with large esophoric deviations who ton, Calif., 1972.
have benefited from an operation. One example 6. Vodnoy BE. The basis for and practice of orthoptics.
Optom Weekly. 1972;63:629-632.
is a college student who had coped with a basic 7. Wick B. A Fresnel prism bar for home visual therapy. Am]
esophoria of approximately 20 A at far and near Optom. 1974;51:576-578.
for many years. She wore 8A BO in her spectacle 8. Vodnoy BE. Aperture orthoptics for the non-strabismic.
lenses and had completed a visin training pro- Am I Optom Arch Am Acad Optom. 1956;33:537-544.
gram. Sheard's criterion was only partially met, 9. Cooper J, Cirton M. Micro computer produced anaglyphs
for evaluation and therapy of binocular anomalies. J Am
even with the compensating prisms in her spec-
Optom Assoc. 1983;54:785-788.
tacles. She had occasional symptoms of astheno- 10. Pratt-Johnson JA, Tillson G. The management of esotropa
pia for many years, especially when fatigued with high AC/A ratio (convergence excess). J Pediatr Oph-
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
approximately 5A eso with a unilateral recession mus. Boston: Butterworth-Heinemann; 1993:80-81.
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.
were mostly abated, she continued regular home 14. Flom MC. Issues in the Clinical Management of Binocular
Anomalies. In: Principies and Practice of Pediatric
visin training to maintain good vergence Optometry. Rosenbloom AA, Morgan MW, eds. Philadel-
ranges, facility, and stamina. This patient's con- pha: Lippincott; 1990:238-239.
dition was treated successfully with a combina- 15. Brock FW. A simple and direct clnical method of control-
tion of several modes of visin therapy (i.e., ling the squinter to normal visual habits. J Am Optom
lenses, prisms, visin training, and surgery). Sur- Assoc. 1941;! 3:132-145.
Chapter 14 / Vision Therapy for Exo Deviations

Diagnostic Considerations 400 Vision Vectograms and Tranaglyphs 410


Therapy Sequence for Comitant Convergence Training at Near
Exotropia 400 (T14.9) 411
Correction of Refractive Error 401 Convergence Walk-Aways (T14.10) 411
Elimination of Major Sensory Profected Base-Out Slides (T14.11) 411
Anomalies 401 Aperture-Rule Trainer (Single Aperture)
Gross Convergence Training 401 (TI 4.12) 412 Pencil Push-
Compensating Prisms and Lens Ups and Push-Aways
Additions 402 (T14.13) 412
Sensory and Motor Fusin Training 403 Chiastopic Fusin (T14.14) 414
General Considerations 403 Changing Binocular Accommodative Rock
Viewing Distance 403 Efficacy of (T14.15) 416
Treatment 404 Surgical Management Vergence Rock Techniques 417
404 General Considerations 404 Efficacy Televisin Trainer and Prisms
of Treatment 404 Follow-Up Care 405 (T14.16) 417
Vision Therapy Sequence for Exophoria 405 Bar Reader with Prisms (TI 4.17) 418
Specific Training Techniques 406 Framing and Prisms (T14,18) 418 Pola-
Voluntary Convergence (T14.1) 407 Mirror Vergence Techniques
Amblyoscopic Convergence Technique (T14.19) 418 Computerized
(T14.2) 407 Convergence Training
Peripheral Fusin Rings (T14.3) 408 (T14.20) 418
Bernell Mirror Stereoscope (T14.4) 408 Case Management and Examples 419
Physiologic Diplopia 409 Brock String Divergence Excess Exotropia 419
and Beads (T14.5) 409 Three-Dot Management Principies 419 Case
Card(T14.6) 409 Brewster Stereoscope Example 420 Basic Exotropia 421
410 Isometric and Step Vergences Management Principies 421 Case
(TI 4.7) 410 Stereoscope Tromboning Example 422
(T14.8) 410 Convergence Insufficiency Exophoria 423
Management Principies 423 Case
Exampie 426

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

ture review involving 740 cases of ntermittent XT,


23
Coffey et al. reported a functional cure, by their
strict criterion, of 59% when visin training was Efficacy of Trea tmen t
used as the sol therapeutic option. The literature on surgical management of ntermittent
XT leaves much to be desired. Patients frequently
regress to their previous deviation, often needing
Chapter14 405

mltiple operations for a successful outcome. Fre-


quently, surgery is unsuccessful or only partially suc- TABLE 14-3. Results of Surgical and Nonsurgical
cessful. Intermittent XT s probably one of the most Treatment of Intermittent Exotropia:A Retrospective
difficult problems faced by strabismus surgeons. Flax Study of 673 Cases
31
and Selenow reviewed 22 journal articles dealing
with surgical success in XT. They reported only a Fair Poor
No. of Good
34% success rate using as a definition of functional Cases {%)
cure a phoric condition at al I distances, sensory
11 36 28 36
fusin, and demonstrable vergence ranges. The fail- Occlusion only Surgery
264 42 41 17
ure rate, as defined by the authors, was 22%, al I only Surgery and
216 52 38 10
other cases falling in between. In a later review by training Training only
23 182 59 36 5
Coffey et al., surgical success for intermittent XT Source: Modified from EL
had apparently improved and was reported as 46% Cooper, IA Leyman. The manage-rnent of intermittent XT: a
on the basis of an accumulated total of 2,530 cases. comparison of the results of surgical and nonsurgcal treatment,
Am OrthoptJ. 1977;27:61-67.
A particularly revealing study that compared
results of different treatment modalities was that
10
of Cooper and Leyman. In this retrospective
study of 673 cases, orthoptics alone had the high- Follow-Up Care
est success rate (59%) and lowest failure rate Compensating prisms (Fresnel) and minus-add
(5%), as compared with the three other therapeu- lenses should be given to the postoperative patient
tic approaches: (1) occlusion only; (2) surgery as soon as possible to aid the development and
only; and (3) orthoptics and surgery (Table 14-3). maintenance of sensory and motor fusin. Patching
The authors pointed out, however, that the an eye s not recommended unless there are surgi-
smaller deviations tended to be found n the cal complications such as an infection. Vision
orthoptics-only group and the larger angles of training can usually be started approximately 2
strabismus n the two surgical groups. For this rea- weeks after the operation without excessive dis-
son, these data are not exactly comparable. comfort. If fusional skills exist at near, we usually
Nonetheless, when surgery and orthoptics are recommend home training exercises (e.g., Mini-
combined, success tends to ncrease and failure vectogram [T14.9], chiastopic fusin [T14.14],
rates diminish. binocular accommodative rock [T14.15], and ver-
On the basis of the many studies of therapeutic gence rock techniques [T14.16 and T14.17]). Any
efficacy for XT, despite their scientific nadequa- of these techniques can also be used as a retainer
cies, we believe that the following treatment rec - exercise for the patient, to monitor regressions and
ommendations can be made with assurance: to give periodic booster training as needed, per-
haps once monthly. Regular progress evaluations
A
1. In cases of intermittent XT of 25 or less (far are scheduled consistent with fusional results of
or near or both), visin training is the pre- therapy.
ferred treatment option and may be com
bined with occlusion, prism compensation,
23 32
and minus adds, as each case demands. - VISION THERAPY SEQUENCE
A
2. In cases of XT greater than 25 at far or near FOR EXOPHORIA
or both, surgery becomes increasingly nec-
essary to effect a cure as the angle of devia- Management of XP s similar to that of XT, although
tion increases. The amount of fusional there are slight differences and therapy is less inten-
control of the deviation s an mportant fac sive (Table 14-4). The clinician usually is not con-
tor. Constant XT is far more likely to require cerned with amblyopia, ARC, or deep suppression.
an operation than is intermittent XT. Correcting the refractive error, providing prism pre-
3. In cases of XT (constant or intermittent) scription, and initiating a short course of visin
requiring surgery, visin training and optical training are the principal modes of therapy in cases
compensation used n conjunction increase of XP. Patients are often highiy motivated and coop-
the likelihood of a successful outcome (see erative in visin therapy; they want relief from their
10 33
Table 14-3). - asthenopic symptoms and, n many cases, wish to
406 Chapter14

Symptomatic exophoric patients frequently have


TABLE14-4. Vision Therapy Sequence for Exophoria shallow suppression that can be identified by (1) the
patient's inability to see double at the endpoint of
the nearpoint of convergence (NPC); (2) lack of
1. Correctlon of any significant ametropia, even mod perception of physiologic diplopia; and (3) evi-
rate to high hyperopia
dence of foveal suppression while vergence ranges
2. Training basic ocular motility of each eye: fixation,
are being tested. Conveniently, physiologic diplo-
saccades, pursuits, and especially accommodation
pia awareness training can be combined with
3. Antisuppression therapy to establish awareness of
building of gross convergence and with training for
physiologc diplopia
voluntary convergence.
4. Development of normal gross convergence ampli-
tude, including voluntary convergence abity Motor fusin ranges, free of suppression, should
5. Central sensory and motor fusin training to be increased maximally in the horizontal, vertical,
achieve good stereopsis and mximum fusional ver- and torsional directions and for all distances, while
gence ranges, free of foveal suppression, at all fusional convergence ranges are emphasized. Most
viewtng distances visin therapists also introduce training techniques
6. Development of good binocular efficiency skills for vergence facility (step and jump) at this stage in
(e.g., facility and stamina of accommodation and the sequence. Isometric training techniques should
vergence; normalize fixation disparity curve) also be assigned, because they help to increase ver-
7. Prescription of compensatory prisms and added gence amplitude and stamina.35 Therefore, these two
tenses as needed steps (training of vergence ranges and building binoc-
8. Maintenance home exercises and periodic progress ular efficiency skills) often are applied simulta-
checkups neously, until relase criteria have all been achieved.
(See the section Case Management and Examples.)
In those cases of XP in which training has not
improve vocational or avocational performance that resolved all the signs and symptoms of a dysfunc-
is affected by nefficient visual skills. Fortunately, tion, prism compensation serves as a convenient
progress in visin training is usually rapid. option. Fortunately, patients with symptoms associ-
We initially suggest visin training rather than ated with heterophoria usually do not experience
prism compensation in most symptomatic XP cases. prism adaptation; the prism effectively compen-
The reasoning is that developing good visual func- sates for the condition.19 We have seen a few
tion is preferable to relying on a crutch. Further- symptomatic exophores who did not respond suc-
more, most patients do not require prisms for visual cessfully to compensating prisms due to abnormal
comfort and efficiency after a successful training vergence (prism) adaptation. Principal examples
program. Some doctors, however, prefer to pre- are patients with a type IV fixation disparity curve.
scribe prism compensation to determine whether Even visin training was not always effective in
symptoms diminish or disappear, thus avoiding the eliminating symptoms in such cases. A possible
inconvenience and effort necessary to maintain a alternative is to resolve the patient's symptoms
training program. Whichever approach the doctor with a monovision prescription for spectacles or
chooses, it should be pursued with informed con- contact lenses (see Chapter 16).
sent of the patient after the options have been thor- Most cases of XP (at least 70%)8 are managed
oughly explained. successfully with visin training within a 6- to 8-
XP often is associated with accommodative week period. It is wise to give patients retainer
deficiencies, particularly accommodative insuffi- exercises to prevent regression, although regres-
ciency.34 We recommend training the accommo- sion is seldom significant if the patient has met all
dative dysfunction initially, if present, before relase criteria.36
effort is expended on convergence training.
(Accommodative anomalies tend to have greater
adverse effect on vergence than vice versa.) Also, SPECIFIC TRAINING TECHNIQUES
training of accommodative skills progresses rap-
idly, thus increasing patient motivation. (See Twenty visin training techniques are presented
Chapter 16 for a discussion of training accommo- that are particularly appropriate for exo deviations.
dative skills.) There are, however, many other techniques that
Chapter14 407

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.

Voluntary Convergente (T14.1)


Voluntary convergence is the willful crossing of the Amblyoscopic Convergence
eyes. The definition implies the lack of visual stim- Technique (T14.2)
uli. Most exotropic patients can be taught voluntary In cases of constant XT when suppression is deep and
convergence. The mechanism each person uses is fusin cannot be established with voluntary conver-
not always known, but t is mportant to note that t gence, amblyoscopic convergence training can be
can be learned, regardless of how it is achieved. If used to achieve sensory fusin. Ratients are, ideally,
visual stimuli help in the learning process, their use scheduled for hourly sessions, two or three times
is fine. Some patients imagine seeing visual objects, weekly. Constant occlusion is required when the
such as a bug flying near the nose, to trigger the patient s not actively training, to help break any
convergence response. After sufficient repetitive existing suppression. The first sudes introduced n the
exercises, the patient begins to be aware of the amblyoscope are usually first- or second-degree
proprioceptive feeling of his or her eyes being con- peripheral targets, n an attempt to establish rudimen-
verged, as opposed to being in the fusion-free exo tary fusin at the objective angle of strabismus. Sup-
deviated posture. The doctor and therapist can mon- pression is broken with autornatic, rapid, altrnate
itor the extent of convergence by using the Hirsch- flashing and by dimming the image of the nonsup-
berg test and giving the patient feedback when the pressing eye. Initially, the patient's task s to use men-
eyes are in the ortho posture. The feeling the patient tal effort to hold in view the suppression controls for
experiences at that moment should be remembered each eye simultaneously for a required time nterval
and recaptured every time the eyes assume the (e.g., 1 minute). When this goal is achieved, the stim-
ortho posture. Once the patient knows this feeling ulus characteristics of the targets are changed to chal-
and can bring it about at will, he or she can practice lenge the patient further, and the process s repeated.
voluntary convergence at home. Once suppression s consistently broken on a
Voluntary convergence can also be aided by second-degree target set at the patient's angle of devi-
awareness of diplopia. The exotropic patient may ation, motor fusin demands can be ntroduced. The
have trouble noticing pathologic diplopia, because amblyoscope s designed to build sliding vergence
point zero is on the temporal retina. If the patient is ranges in horizontal, vertical, and cyclotorsional
unable to perceive pathologic diplopia, training directions. In cases of XT, expanding convergence
designed to promote the awareness of physiologic ranges are, of course, the primary concern, but build-
diplopia should be given. (See Chapter 1 for dis- ing motor fusin skills in the other directions is ideal
cussions on pathologic and physiologic diplopia.) for the sake of generalization and reinforcement of
An example of physiologic diplopia awareness learned skills. A reasonable goal for fusional conver-
training n conjunction with antisuppression train- gence in the major amblyoscope is at least 20A from
ing s the Brock string and beads technique (TI2.7) the angle of deviation without suppression. When
discussed in Chapter 12. this level of skill s achieved, and perhaps even a
The voluntary convergence technique can sup- lesser level when the XT s of small or modrate mag-
plement the gross convergence technique (T11.13) nitude, the patient can then learn to apply voluntary
that has been previously described as a treatment vergence movements to achieve and maintain fusin
for ARC associated with XT. This technique also in the open environment. For the sake of efficiency
applies in cases of constant XT at near with NRC; and effectiveness of training, every effort should be
however, afterimages are unnecessary to monitor made to transfer the patient out of the instrument and
covariation, as the correspondence is normal. into the open environment as soon as possible.
408 Chapter14

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

fusional recoveries is recorded at each training ses-


sion, to chart progress and to enhance motivation.

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

PIN not necessarily comfortably. The patient monitors


the suppression clues as fusin is held for a spe-
POHTION
REMOVED
cific period (e.g., 2 minutes). Flashing, blinking,
PATIENT
and increased illumination can be used to break
suppression if it occurs. The patient completes at
least four sets lasting 2 minutes each, separated by
short rest periods. With continued training, com-
fort should be gradually achieved.
When progress reaches a plateau, the patient is
FIGURE 14-2Three-dot convergence card from which top portion introduced to step vergences. A stereogram with
has been cut off to faciltate bifixation. A pin is shown that can be
stuck on the card to promote fusin of the middle-sized pair of dots
two pairs of targets on one stereogram, such as the
(actually half-dots) n this example. example shown in Figure 13-5, is presented to the
patient. The bottom pair of targets should have a
BO demand approximating that of the isometric
quick jump vergence responses without suppres- mximum and the top pair should have a lesser
sion are achieved. When suppression is noticed, BO demand. The patient is nstructed to altrnate
the patient blinks his or her eyes and wiggles the fixation from top to bottom to top and so on,
card slightly to re-establish perception of physio- attempting to increase vergence facility. This rou-
logic diplopia. Near-far jump vergence can also be tine is repeated for a specified number of minutes
trained by having the patient altrnate fixation or cycles, whichever is recommended.
between a distant object and the three-dot card.
The goal of these jump exercises is to improve ver- Stereoscope Tromboning (T4.8)
gence facility as well as the NPC. The therapist can Stereoscope tromboning in cases of exo deviations is
make these exercises easier for the patient by using similar to that for eso deviations (T13.4). (However,
minus adds or Bl prism; in contrast, the level of dif- an mportant training feature of the Brewster Stereo-
ficulty can be raised with plus adds or BO prism. scope for farpoint exo deviations is that BO demand
This jump vergence training is effective but very is produced as the target is tromboned farther away.)
demanding; patients will need to rest after each 2- The patient is instructed to maintain fusin while
minute training interval. slowly moving the stereogram back and forth from
near to far. This is especially applicable in DE and BX
Brewster Stereoscope cases. For example, a stereogram with a target sepa-
ration of 63 mm has an ortho demand at the near
The optics of the Brewster Stereoscope were dis-
setting (simulated 40-cm distance) but has a BO
cussed in Chapter 13, as was its application to
demand of 12A at far (simulated 6-m distance). This
visin training in cases of esotropa and esophoria.
is a paradoxical sensation for the patient, who natu-
The same principies apply for exo deviations
rally associates divergence with a receding target
except that the emphasis in these cases is on
(rather than convergence of the eyes at greater dis-
fusional convergence training with BO demands.
tances). This dissociative maneuver on accommoda-
The Brewster Stereoscope s an mportant training
tion and vergence "shakes up" the patient's sensory
instrument for farpoint exo deviations, because the
and motor fusin pattern, thus creating a novel,
stereograms can be placed at optical infinity. For
motivating, and effective training technique.
this reason, this instrument s used in cases of DE
and BX but infrequently in Cl cases.
Vectograms and Tranaglyphs
Isometric and Step Vergences (T14.7) Isometric Vectograms and Tranaglyphs are open environ-
vergence training is used when the mximum BO ment training materials, described in Chapter 13
demand can be met with the patient fus-ng and (T13.8-T13.10), that can be used in the office or at
seeing the target clearly. The patient is shown a home and are distinguished by the variety of well-
series of stereograms with varying separa-tions, designed and interesting targets with stereopsis
and the one selected is that with mximum BO and suppression clues. In XT and XP, the emphasis
demand in which the patient can reasonably is on developing and expanding suppression-free,
maintain clear, single binocular visin, although fusional convergence ranges and step convergence
Chapter14 411

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

FIGURE 14-3Patient performing con-


vergence training with the Aperture-
Rule Trainer with a single aperture.

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

FIGURE 14-4Aperture-Rule Trainer with


a single aperture being used for nearpoint
fusin training. Fixation targets at far can
be included for jump vergence training. A
metronome can be incorporated to pace
the vergence demands. The arrows chal-
lenge the patient's directional skills to pro-
mote automaticity of vergence.

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

age clinicians to use their magination, or better still,


a patient's particular interests for selecting a push-up
target. We have had success using toy cars, stamps,
stickers, coins, candies, and other small objects that
are of unique nterest to the patient. And remember,
n visin training, var/efyspells success.

Chiastopic Fusin (T14.14)


Chiastopic fusin and the Aperture-Rule Trainer are
based on the same principie (Figure 14-5). Both tech-
niques provide BO demands for improving fusional
convergence. The difference s that there is no aper-
ture involved n chiastopic fusin; thus, it s truly a
free-space technique. Chiastopic fusin is the cross-
ing of the visual axes (as n the Greek letter chi,
which resembles the letter X) at the plae where the
aperture would ordinarily be. Chiastopic fusin is dif-
ficult at first for most patients, especially younger
patients, because there is no aperture to help direct
the patient to the crossing point. In accord with
Piaget's cognitive concepts, it is unlikely that patients
younger than 7 years will be able to master chias-
topic fusin (see Chapter 9).
A good technique initially is the use of the Key-
stone Colored reles (Lifesavers) Card (Figure 14-6).
FIGURE 14-5Chiastopic principie with a single aperture. The visual
The patient s instructed to follow a pencil tip placed
axes cross at the plae of the septum, intersection of an X resembling
the Greek letter chi. between him or her and the card, which is approxi-
mately 40 cm away. The pencil should be moved
back and forth slowly while being bifixated, until the
Vergence facility s trained using a jump vergence patient can perceive four circles from a single pair
technique. The pend is placed just beyond the (.e., each of the two seen diplopically, because of
NPC, and the patient fixates a far target. For motiva- physiologic diplopia). When the pencil s at exactly
tional purposes, we suggest a small televisin tuned the correct distance (as with the aperture of the Aper-
to a commercial channel, but any distinct object will ture-Rule Trainer), three circles should be perceived.
suffice, particularly a clock. At each commercial The middle circle is that which is fused, and the out-
break, the patient completes as many cycles of jump side two are merely the diplopic images. These
vergence eye movements as possible between the unfused circles act as peripheral suppression clues.
televisin and the pencil, always noting or establish- Central suppression clues are the missing letters for
ing physiologic diplopia beforethe next jump is initi- each eye or the clinician's modification of added
ated. The goal here, of course, is to increase speed of symbols such as arrows (Figure 14-7). The patient is
jump vergence eye movements without suppression. nstructed to continu this technique until chiastopic
Accommodative facility can be trained in much fusin can be achieved voluntarily and quickly. If the
the same way as is vergence facility but using an fused target appears blurred, the card may be moved
alphabet pencil (letters printed on the pencil) or a slightly and slowly back and forth to achieve clear-
detailed sticker attached to the pencil that serves ness. If that fails, the patient may try wearing minus
as an effective accommodative stimulus. The thera- adds to help convergence and to extend the focus out
pist's familiarity with this modification is impor - to the plae of regard. (Note that exophoric or exo-
tant, because accommodative infacility often is tropic patients usually overaccommodate to enlist
associated with convergence insufficiency. '
8 34 accommodative convergence as an aid in the chias-
The technique of pencil push-ups has become topic fusin task.) The goal for the patient is to
traditional n visin training, but we would encour- achieve chiastopic fusin quickly and with clarity
Chapter14 415

FIGURE 14-6Chiastopic fusin train-


ing with the use of Keystone Colored Cir-
cles (Lifesaver card). a. Use of pencil to
aid convergence and teach patient to
cross-fuse. b. Chiastopic fusin without
the use of pencil as aid to convergence.

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

18). Another goal s for the patient to perceive SILO


("small-in, large-out"). As the patient converges to
meet greater BO demands (sliding vergence) as the
targets are more widely separated, the middle fused
target typically appears to be getting smaller
("small") and sometimes closer ("in"). This is a size
constancy perceptual phenomenon and not a stere-
opsis response based on lateral disparity differ-
ences. Conversely, with the SILO effect, as the BO
demand s reduced by decreasing the separation
distance of the cards, the fused image appears to be
getting larger ("large") and sometimes can be per-
ceived as receding ("out"). The SILO effect is moti-
vational and fascinating to patients and is a good
check indication to the therapist that the patient is
performing the prescribed technique properly.
Jump vergence training can be done with either
the Lifesaver card or eccentric circles. The patient
makes jump vergence eye movements from a chi-
astopically fused image at near to a distant object,
such as a doorknob. A specific number of cycles or
a specific time should be assigned for home train-
ing, and the patient should record his or her results
daily. Increasing both the amplitude of the jump
and speed are training goals.
For DE and BX cases, the chiastopic technique is
performed at far and can be done with two similar
pictures for fat fusin, as in Figure 14-8. The tech-
FIGURE 14-7Modification of the Keystone Colored Greles for mon-
toring suppression. The missing letters and added drawings of arrows
nique can be carried out with stereopsis targets by
monitor central suppression. Peripheral suppression is monitored by using enlarged eccentric circles, either homemade
determining whether there is perception of three circles when the or purchased (e.g., Keystone Eccentric Circles).
middle is being chiastopically fused. Vertical marks, such as arrows,
serve also to monitor fixation disparity during forced convergence.
Most DE or BX patients find it difficult to begin chi-
astopic fusin at far. Training at near on this tech-
nique is almost always essential before the fixation
distance can be extended to far. Considerable time
discussed in Chapter 13 as a technique for orthopic
is required for success in performing this technique,
(Bl) fusin training (T13.15) in cases of eso devia-
perhaps several weeks for some patients. The
tions; the difference in training in cases of exo devia-
patient's goal is to achieve chiastopic fusin at a dis-
tions s that chiastopic (BO) fusin training is what is
tance of 3 m or farther and to be able to do this
needed. A validity check by the therapist will deter-
quickly (phasic training) with clear visin, to per-
mine whether the patient is actually performing chi-
ceive stereopsis, and to have no suppression. The
astopic rather than orthopic fusin; the patient's
patient should be able to hold fusin (isometric
perception of the floating circle is the key. In Figure
training) comfortably for periods of 2 minutes.
13-18, the small circle n the chiastopically fused
image should appear to float farther away than the
larger circle when the cards are placed with the As Binocular Accommodative
opposite each other. If the patient reports that the
Rock (T14.15)
smaller circle s floating toward him or her, the thera-
As in eso deviations (T13.11), binocular accommo-
pist knows that the patient is performing orthopic
dative rock can be used to increase accommodative
fusin rather than chiastopic fusin.
and convergence skills of exotropic and exophoric
The goal for the patient is to achieve a BO range
patients. The clinician should ensure good monocu-
comparable to the very strong vales usted in Chap-
lar accommodative skills before proceeding to bin-
ter 2 for blurpoint, breakpoint, and recovery (23/287
Chapter14 417

FIGURE 14-8Chiastopic fusin train-


ing at far. Two similar pictures are
cross-fused. The special markings act as
suppression clues.

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>>

FIGURE 14-9Framing tech-


nique for exo deviations. a. As
the patient views a distant pen-
light, the perception s diplopia
of a pencil at an intermedate
distance. b. Cyclopean illustra-
tion of framing based on physi-
ologic diplopia.

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

I Relief from Symptoms


o
tu
(/>20 2.0
10

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
REFERENCES apy for treatment of intermittent exotropia. Ophthalmol-
1. National Center for Health Statistics. Refractiva Status and ogy. 1983;90:1160-1165.
Motility Defects of Persons 4-74 Years. National Health 22. Rutstein RP, March-Tootle W, London R. Changes in
Survey 206, 1971-1972. United States Vital and Health refractive error for XTs treated with overminus lenses.
Statistics, Series 11. Hyattsville, Md.: DHEW Publications, Optom Vis Sci. 1989;66:487-491.
1978. 23. Coffey B, Wick B, Cotter S, et al. Treatment options in
2. Schlossman A, Boruchoff SA. Correlation between physio- intermittent XT: a critical appraisal. Optom Vis Sci.
logic and clinical aspects of XT. Am J Ophthalmol. 1955; 1992;59:386-404.
40:53-64. 24. Sanfilippo S, Clahane A. The Immediate and Long Term
3. Simons HD, Grisham JD. Binocular anomalies and read Results of Orthoptics in Exodeviations. In: The First Inter
ing problems. J Am Optom Assoc. 1987;58:578-587. national Congress of Orthoptists. St. Louis: Mosby; 1968:
4. Simons HD, Gassler PA. Vision anomalies and reading 299-312.
skills: a meta-analysis of the literature. AmJ Optom Phys- 25. Goldrich SG. Optometric therapy of divergence excess
iolOpt. 1988;65:893-904. strabismus. AmJ Optom Physiol Opt. 1980;57:7-14.
428 Chapter14

26. Ludlam W, Kleinman B. The long term range results of sustained mprovement after short isometric exercise. Am
orthoptic treatment of strabismus. Am J Optom Arch Am ] Optom Physiol Opt. 1979;56:23-33.
AcadOptom. 1965;42:647-684. 36. Pantano F. Orthoptic treatment of convergence insufficiency:
27. Cooper J. Intermittent XT of the divergence excess type. J a two year follow-up report. Am OrthoptJ. 1982;32:73-80.
Am Optom Assoc. 1977;48:1268-1273. 37. Kertesz AE, Kertesz J. Wide-field fusional stimulation in
28. Helveston EM. Surgical Management of Strabismus: An strabismus. Am J Optom Physiol Opt. 1986;63:21 7-222.
Atlas of Strabismus Surgery, 4th ed. St. Louis: Mosby; 38. Wick B. Visual therapy for constant XT with anomalous
1993:435-442. retinal correspondence: a case report. Am J Optom Phys-
29. Souze-Dias C, Uesugue CF. Postoperative evolution of the /o/Opf. 1974;51:1005-1008.
planned initial overcorrection in ntermittent XT: 61 39. Goldrich SG. Oculomotor biofeedback therapy for XT.
cases. Binocul Vis Eye Muscle Surg Q. 1993;8:141-148. AmJ Optom Physiol Opt 1982;59:306-317.
30. Jampolsky A. Adjustable Strabismus Surgical Procedures. In: 40. Kent PR, Steeve JH. Convergence nsufficiency; incidence
Symptoms on Strabismus, Transaction of the New Orleans among military personnel and relief by orthoptic meth-
Academy of Ophthalmology. St. Louis: C.V. Mosby; 1978: ods. Mil Surg. 1953;112:202-205.
320-328. 41. Daum KM. Convergence insufficiency. Am J Optom Phys
31. Flax N, Selenow A. Results of surgical treatment of nter iol Opt. 1984;61:16-22.
mittent divergent strabismus. Am J Optom Physiol Opt. 42. Cooper J, Selenow A. Ciuffreda KJ, et al. Reduction of
1985;62:100-104. asthenopia in patients with convergence insufficiency
32. Singh V, Roy S, Sinha S. Role of orthoptic treatment in the after fusional vergence training. AmJ Optom Physiol Opt.
management of ntermittent XT. Indian J Ophthalmol. 1983;60:982-989.
1992;10:83-85. 43. Wick B. Vision training for presbyopic nonstrabismic
33. Carta A, Pinna A, Aini MA, et al. Intermittent XT: evalua- patients. Am J Optom Physiol Opt. 1977;54:244-247.
tion of results on the basis of different treatments. J Fr 44. Cohn AH, Soden R. Effectiveness of visual therapy for
Ophtalmol. 1994; 17:161-166. convergence insufficiencies for an adult population. J Am
34. Daum K. Characteristics of exodeviations: 1. A comparison Optom Assoc. 1984;55:491^94.
of three classes. Am J Optom Physiol Opt. 1986;63:237- 45. Daum K. A comparison of the results of tonic and phasic
243. vergence training. Am ] Optom Physiol Opt. 1983;60:769-
35. Veagan. Convergence and divergence show longer and 775.
chapter 15 / Management of Noncomitant Deviations,
Intractable Diplopia, and Nystagmus

Infantile Noncomitant Deviations 429 Diagnosis 438 Optical Management


Diagnosis 429 438 Vision Training 439 Afteiimage Tag
Management 429 Acquired Teehniques (T15.3) 440 Intermittent
Noncomitant Deviations 430 Photic Stimulation
Diagnosis 430 (TI 5.4) 440
Occlusion 430 Auditory Biofeedback (TI5,5} 441
Prism Compensation 432 Surgical Management 441 Acquired
Ocular Calisthenics 433 Nystagmus 443 Diagnosis 443
Sensory and Motor Fusin Training 433 Management 443 Case Examples 444
Fusin Field Expansin (T15.1) 434 Case 1: Duane Retraction Syndrome 444
Double Maddox Torsin Training (T15.2) Case 2: Noncomitant Intermittent
434 Hypertropia 446
Surgery and Follow-Up Management 434 Case 3: Acquired Third Nerve Palsy 447
Intractable Diplopia 435 Case 4: Intractable Diplopia 448 Case 5:
Diagnosis 435 Congenital Nystagmus 448
Occlusion Strategies 436
Prism Displacement 437
Hypnotherapy 437
Congenitai Nystagmus 438

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

indicated in such cases to confirm or establish the


TABLE15-1. Management of Acquired diagnosis. The mostcommon noncomitant deviations
Noncomitant Deviations are the sixth and fourth nerve palsies, n that order.
(See Chapters 4 and 8 for strabismus diagnosis.) The
specific etiology of the condition should be estab-
1, Referral for medical management of the primary
lished, if possible, and professionally managed.
ettologic factor(s)
Our management approach for acquired non-
2, Correction of any significant refractiva error
comitant strabismus s not based on a wait-and-see
3, Prescription of Fresnel prism to promote fusin in a
attitude. Efforts are directed toward preventing
particular field of gaze and viewing distance
4, Altrnate patching to prevent dlplopla, prevent diplopia and contractures, re-establishing fusin at
corrtractures, and exercse the paretic mustie some fixation distance, and actively expanding
5, Visin training: ocular calisthencs n the affected ocular motility and binocular visin during the ini-
field of gaze to prevent contractures and remed tial recovery period. Vision training, n these cases,
ate eye movernents is viewed as a form of physical therapy for eye
6, Vision training: sensory and motor fusin training movernents (Table 15-1).
to build fusional control of deviation
7, Consideration of need for strabismus surgery after
6-8 months of healing and visin therapy Occiusion
Diplopia s the most pressing problem facing
patients with recent onset of extraocular muscle
at treatment, and associated conditions, along with paresis. This annoyance can easily be eliminated
other factors; therefore, it s difficult to make general by prescribing an occluder to be worn over the
statements pertaining to all types. The clinician starts affected eye. Although this has been the traditional
with correction of any significant refractive error. method in paretic cases, generally it s better to
Occiusion and visin training may be indicated for recommend altrnate occiusion rather than confin-
amblyopia and eccentric fixation, f they exist, even ing the patch to the paretic eye. Occluding the
f the prognosis of normal binocular visin is remote. sound eye may provide beneficial stimulation to
If anomalous retinal correspondence (ARC) exists the paretic eye that can lead to eye movernents
(although rare in acquired noncomitancy), we usual into the field of action of the paretic muscle. Patch-
ly recommend that no attempt be made to establish ing the unaffected eye may reduce the risk of sec-
normal retinal correspondence (NRC), as diplopia is ondary contracture of the homolateral antagonist
a likely consequence. Surgical alignment of the eyes of the affected eye. For example, if the right lateral
stands as the principal treatment, especially if the rectus muscle (RLR) is paretic, patching the left eye
noncomitant strabismus s of neurogenic origin. (Dis- might encourage the patient occasionally to
cussion of surgical methods for these varied cases is abduct the right eye to view objects in right gaze.
beyond the scope of this text.) Patients needing an This should occur unless the patient has become a
operation, which can be complex, should be referred head turner. When the patient abducts the right
to a strabismologist (ophthalmologic specialist) rather eye, the right medial rectus (RMR; the homolateral
than a general ophthalmologist for evaluation and antagonist) relaxes and, consequently, may help to
treatment after the aforementioned management prevent contracture of that muscle.
steps have been completed. Continuous patching of the nonparetic eye can
lead to trouble, because contracture may develop
in the contralateral synergist. In this example of a
ACQUIRED NONCOMITANT paretic RLR, the yoke muscle s the left medial rec-
tus (LMR), which will overact (risking contracture
DEVIATIONS
because of Hering's law) when abduction is
Diagnosis attempted with the right eye. Therefore, altrnate
When a patient of any age presents with an acquired occiusion is preferable because of the possibility of
noncomitant strabismus, often accompanied with contracture of either the homolateral antagonist
reports of diplopia, an active neurologic condition (e.g., RMR), when the affected eye is occluded, or
must seriously be considered and ruled out. Often, a the contralateral synergist (e.g., LMR), when the
referral to a neurologist or neuro-ophthalmologist is sound eye is patched (Figure 15-1).
Chapter15 431

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.

Binasal occlusion can also be applied to pre-


vent diplopia and contractures n cases of sixth
nerve palsy. Binasal strips of opaque tape are
positioned on spectacle lenses to promote alter-
nation of fixation (see Chapter 11). The right eye
is used for fixation in the right field of gaze, and
the left eye is used for left gaze. In this way,
RELAXATION
OFLMR abduction of each eye is continuously encour-
aged and thereby prevents contracture of the
medial recti. The procedure works well with
cooperative adults who understand the impor-
FIGURE 15-1Altrnate occlusion for prevention of contractures.
tance of alternately abducting each eye as much
a. Paresis of the right lateral rectus muscle (RLR) with contracture of
left medial rectus (LMR). b. Occlusion of the nonparetic eye to pre- as possible. Young children, however, are less apt
vent contracture of the right medial rectus muscle (RMR). c. Occlu- to cooperate fully and tend to become head turn-
sion of the paretic eye to prevent contracture of the LMR. ers, using only one eye for fixation. Total unilat-
eral occlusion, alternated on a daily basis, s
Although altrnate occlusion seems the best recommended in such nstances.
approach to prevent diplopia and contractures, Partial occlusion can be used to prevent diplo-
there s another mportant consideration. When the pia n some cases of mild paresis. If the patient has
unaffected eye is patched and the patient looks into a mild RLR paresis, for example, with diplopia
the field of gaze of the affected muscle (e.g., RLR), only in right gaze, the temporal portion of the right
past pointing may occur. Because excessive inner- spectacle lens can be occiuded (Figure 15-2a). This
vation must be sent to the paretic muscle, the type of occlusion allows the patient to maintain
patient misjudges the spatial position of the target. fusin n the primary position and in left gaze,
As the patient practices eye-hand coordination with which s therapeutically desirable, possibly with a
the nonparetic eye occiuded, however, the disturb- slight right head turn. Diplopia s prevented with a
ing sensation and misperception of direction versin eye movement to the right field. A Fresnel
reduces or disappears. During all critical viewing prism may also be tried (see Figure 15-2b). Partial
tasks, such as driving or eye-hand coordination patching does not prevent contracture; fortunately,
required on the Job, the patient should simply contracture is usually not of serious consequence
occlude the paretic eye to avoid this problem. in cases of mild paresis.
432 Chapter15

tasks, as when an aid is prescribed for a low-vision


patient. The prisms usually do not result in fusin
in al I fields of gaze but are used by the patient for a
specific task for the sake of maintaining fusin and
\/ promoting recovery of the paretic condition. The
prism spectacles can be worn for 1-4 hours per
day for specific activities, and the Fresnel prism
can be removed when the patient performs other
tasks. The power should be on the conservative
side, with the patient wearing just enough prism to
maintain fusin and yet remain comfortable.
Weaning the patient from the prism is gradual,
reducing the powers commensurately with remis-
sion of the paresis and mprovements in fusional
control of the deviation.
In some cases, the Fresnel prism might best be
placed before the nonaffected eye, thereby lessen-
ing potential contracture of the homolateral antag-
onist. For example, in the case of a right esotropa
(paretic RLR), an appropriate-power base-out (BO)
Fresnel prism that gives fusin could be applied to
the left spectacle lens; it should be remembered
that the amount of prism needed to neutralize the
secondary deviation is usually larger than that for
the primary deviation. The left eye would then
move in because of the prism, and the right eye
would move out, thus preventing contracture of
the RMR.
When the angle of deviation has both a vertical
and a horizontal component, each component
usually is measured separately, and prisms are pre-
FIGURE 15-3Maddox rod method for simultaneous measurement of
vertical and horizontal deviations. a. Image of Maddox rod of left eye scribed accordingly. However, in working with
and penlight of right eye. b. Maddox rod rotated for superimposition. Fresnel prisms, this method has its limitations
c. Maddox rod rotated 90 degrees, resulting n diplopia. d. Neutraliza-
because two seprate prisms cannot be applied to
tion of the left hypo and eso deviations.
one lens. An alternative procedure for measuring
both components at the same time can be per-
Prism Compensation formed with the Maddox rod vector method (Fig-
ure 15-3), which is quick and fairly accurate. This
If possible in cases of recent diplopia, fusin
procedure, however, requires the patient to have
should be maintained with Fresnel prisms without
NRC and minimal suppression. With a Maddox
resorting to occlusion. This ideal seems achievable
rod over the strabismic eye, the patient fixates a
only when the extraocular muscle paresis proves
small, bright light with the dominant eye (right eye,
to be mild. von Noorden reported, "When a devia-
in this example) at the distance needing prism
tion is less than 10 prism diopters we have found
compensation (see Figure 15-3a). A Maddox rod
prismatic correction to be most effective in delet-
placed before the strabismic eye is rotated so that
ing diplopia." 1 We recommend trying Fresnel
the streak appears to pass through the center of the
prism compensation even in cases of modrate
white light (see Figure 15-3b). This axis is
paresis in which a deviation exists in the primary
recorded. The Maddox rod then is rotated 90
field of gaze at far or near (or both). Fresnel prisms
degrees (see Figure 15-3c). Either Risley or lose
can easily be changed to keep up with changes in
prisms are used with the base oriented to the
the angle of deviation during the healing period. In
recorded axis to neutralize the separation between
cases of modrate paresis, prisms can be pre-
the light and streak (see Figure 15-3d). The prism
scribed for a specific distance and for specific
Chapter15 433

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
30 8
-
y 1 OB
*-
|
7 5
=
J t 7 o
0 f 5
^ 7 ^ 'x 6 / >
v
( * % 25
T
^
25 N " *

"*
,. 50 I
= " ~
^^
*
X -^
4
^ ^1
~ *^ X
. ^ !
* -

Q.
Aft _, .

~-

" ^

^x
^ N
N
X
N
s j
^
\ 4
l \0

-H O

*
.

1

f
Ir
r

&
20

W \
^ V5
ce
o0 -
~_.
-

X
X
s
\
\
\
\
fl S "
i' 3 )e
N
15

^ \ .25
x^ \ \
^ N \ ^ i2
i \
i
^
^
^f s*
\ 3
10

- " \ \ s* \ f 0
-^~H
* \ \
^
- . ^
N
\
N jr*
\ -
^ ' \
\
-\ 1
5
FIGURE 15-4Nomogram for vertical ~-
""
^~ N \ \ ^^ ^ \
and horizontal prism power when '
" ^
^ s| \ s \
s* \ \ \ 10
\
1
using one prism at various orientations ^
*^
of its base. In this example, the base is _ -^ "N
.
^ N\ s V \ \
^
^ \ ^
y \ * \ \ \ 5
oriented 23 degrees out and up for the
N
N
S \\ \
r \ \ -
left eye. In this instance, 8A base-up
and 18A base-out result n a vector ori- _
-^
NV ^ ^
l\
ented 23 degrees with a power of
> *
) i 2 9
approximately 20A. >I
1
i\ 1
D 1 T (LEFT E
2 5 0
1 : OPTERS
I EY )
OU
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.

Fusin Field Expansin (T 5.1) Surgery and Follow-Up


One effective technique for expanding the field of Management
fusin s simply to establish a strong sensory fusin The rate of partial or complete remission n cases
lock n an unaffected field of gaze and to ask the of acute acquired noncomitant strabismus s high,
patient to rotate the head slowly, thereby empha- approximately 70%.4 Unless the affected muscle is
sizing sensory and motor fusin in affected fields completely paralyzed, surgery should not be con-
of gaze. A vivid stereo target, such as the Spriangle templated for at least 6-8 months after the onset of
Vectogram, can be used to stimulate sensory the condition. There are few changes n the angle
fusin. The patient slowly rotates the head so that of deviation after this time unless an active disease
the eyes move into the affected field of gaze while process exists (e.g., mltiple sclerosis, diabetes).
he or she makes a mental effort to maintain the ste- Conversely, stroke or trauma patients usually have
reo percept. As soon as diplopia s noted, the head a stable condition after 6 months. During this inter-
is moved to regain sensory and motor fusin; this val, the conservative approach is to manage the
break-and-join training can continu for a speci- strabismus by the use of lenses, prisms, occlusion,
fied time. An sometric variation of this technique calisthenics, and motor fusin training. These ther-
can be effectively used. The patient moves the eyes apies are performed in conjunction with medical
into a field of gaze in which fusin s difficult but management of the primary condition responsible
can be maintained for several minutes. The patient for the noncomitant deviation.
Chapter15 435

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

an occluder contact lens or even a plstic clip-on


occluder over one spectacle lens. When an opaque TABLE15-2. Management Approaches for
15 Intractable Diplopia
soft contact lens is used, Burger and London rec-
ommend incorporating a fogging element in the pre-
scription (+2.00 to +4.00 D greater than the
Occlusion strategies:
manifest), because all opaque contact lenses transmit
1. Total opaque occlusion
some light. We usually attempt to avoid total con-
A. Bandage or tie-on occtuder; recommended only
stant occlusion because the field of view is reduced. as a temporary solution
The two techniques that we have found most effec- B. Wearing an opaque soft contact lens, a possibly
tive are monovision and central field distortion. acceptable long-term solution
The patient may find that a monovision correc- 2. Monovision optical prescription using contact
tion, with spectacles or contact lenses, provides lenses or single visin spectacles; our preferred
adequate diminution of binocular visin to prevent treatment approach
diplopia awareness under most circumstances 3. Central field distortion: small, centra!, translucent
while allowing the perception of movement n the or opaque spot; stippled clear nail polish
16
retinal periphery of both eyes. London reported a Prism displacement: to increase the separation of
series of ntractable diplopia cases managed suc- diplopic images
cessfully with monovision prescriptions. He rec - Hypnotherapy: patient with a posthypnotic sugges-
ommended correcting a strongly dominant eye for tion to ignore the diplopic image and experience
near using the plus add in single visin spectacles less anxiety; formal hypnosis to be provided by a
or contract lenses. Otherwise, the dominant eye professionally trained psychological counselor
tends to be used for both far and near. The amount
of plus add s determined empirically n each case,
but we have found +2.00 D to +2.50 D to be opti- Also, n cases of ARC, compensatory prisms are not
mum in most cases we have managed. Monovision recommended for long-term management, because
is our preferred treatment option in cases of intrac- the angle of deviation may ncrease as a result of
table diplopia or even long-term uncomfortable prism adaptation. Even some patients with NRC
binocular visin that cannot be resolved using and acquired noncomitant strabismus show prism
conventional treatment. 16
adaptation to horizontal prisms. In such cases,
Central field occluders can also be tried to however, vertical prism displacement may provide
determine which is the most appropriate approach some improvement in the management of diplopia.
17
for a particular patient. This occlusion approach A
A 10-15 base-down Fresnel prism can be used on
can be achieved in various ways as follows: (1) a a trial basis before the nonpreferred eye to see
translucent cellophane tape or contact paper but- whether the diplopic image s easier to ignore or, at
ton cut to approximately the size of a dime; (2) a least, inferieres less under critical viewing condi-
central opaque dot; or (3) a central spot of clear tions. Base-up Fresnel prisms are not well accepted
nail polish that has been stippled to appear like by most patients; the small ridges reflect overhead
shower glass. This approach allows for clear, full- lights into the eyes, causing glare. If the patient
field, peripheral binocular visin, an advantage n does find vertical prism helpful after 1 or 2 weeks
some cases of central metamorphopsia, for exam- of trial wear, spectacle prisms can be ground in,
ple. However, the poor cosmesis of the occluder and the power can be split between the eyes to dis-
may eventual ly be unacceptable to some patients. tribute the weight and thickness. W e have had
some success using inverse prisms to seprate the
images in cases of intractable diplopia.
Prism Displacement
Most patients with i ntractable diplopia do not
respond well to compensatory prisms. In cases of Hypnotherapy
horror fusionis and sensory fusin disruption syn- We have recommended hypnosis as a last-ditch
12
drome, n which the images are closely aligned or therapy for cases of ntractable diplopia in which
overlapped with prisms but fusin does not occur, nothing else has worked. These unhappy patients
patients may find the diplopia more annoying than are referred to a clinical psychologist skilled n
f the images are separated by a large distance. hypnotherapy. The psychologist eval ales and
438 Chapter15

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

mon observation is that the frequency and magni-


tude of nystagmus decreases with convergence.20
If, for example, the patient has an exophoria, the
clinician should evalate the effect of BO prisms
or plus-add lenses on the control of nystagmus.
Metzger21 reported a case of a 10-year-old highly
myopic boy who was given prisms of 6A BO; his
binocular visual acuity improved from 10/100 to
10/40, and reading became comfortable.
If the binocular status can be improved in cases
of esotropa, there often s an improvement in the
characteristics of nystagmus (see the section Case
5: Congenital Nystagmus). The amount of prism
necessary to reduce the nystagmus by placing the
eyes n a fused, converged position vares, depend-
ng on the specifics of each case; the total amount
FIGURE 15-5Example of yoked prisms to dampen nystagmus. a. Nys-
generally ranges between 6A and 20A BO. Fresnel tagmus on left gaze or n primary position. b. Minimal nystagmus on
prisms may be necessary for the higher prescrip- right gaze or with left head turn. c. Patient looking straight at target,
tions. Metzger21 described an albino girl with con- but eyes are in right gaze position because of yoked, base-left prisms.
genital nystagmus, high myopia and astigmatism, a
hearing impairment, latent nystagmus, and an
be ground into spectacle lenses with an accept-
alternating esotropa. Prisms of 15A BO were pre-
able edge thickness, if the eye size and lens
scrbed and gave immediate improvement of the
power are limited.
nystagmic oscillations and visual acuity.
Minus-add lenses have also been used to attempt
to reduce the nystagmus, but this approach may be Vision Training
undesirable n some cases.20 The primary problem Several visin training techniques may be
with minus-add lenses is that an esophoria at near attempted to help to lessen or elimnate nystagmus
may be produced, rendering reading or other sus- in congenital cases. A consistent clnical observa-
tained close-viewing activities uncomfortable. tion regardng nystagmus intensty is that t
Yoked prisms may be used as a means of treat- decreases as binocular visin is enhanced. If a
ing an abnormal head posture associated with patient has insuffcient sensory or motor fusin, the
congenital nystagmus. As an example, consider nystagmus seems to have larger amplitude and
the patient with a left head turn and a quiet zone higher frequency. Because of these observations,
in right gaze. A BO prism over the left eye and an various methods have been attempted to improve
equal base-in (Bl) prism over the right eye will sensory and motor fusin.22 Antisuppression and
shift both eyes and the nuil point to the right, fusional vergence training can be administered
partially relieving the head turn (Figure 15-5). using most of the different instruments and tech-
Small to modrate amounts of head turn (to niques discussed in other chapters. This form of
approximately 15 degrees) can be managed n therapy seems to have a beneficial effect in hetero-
this way. The prisms required for larger amounts phoric cases n which there is already some nor-
are often unacceptable to the patient, owing to mal peripheral sensory fusin, but t has rarely
distortion and cosmesis. Through the prisms, the been attempted in nystagmus cases complicated
eyes appear deviated to an observer, and one by esotropa. Three training methods that have
cosmetic problem s merely substituted for been particularly effectve n the management of
another. It seems that yoked prisms have a role to congental nystagmus are afterimage tag tech-
play but only n borderline cases of abnormal niques, intermttent photic stmulation, and audi-
head posture. For example, f a patient has a 15- tory biofeedback.
degree head turn to the left, 10 A yoked prism
bases-left would reduce the head turn by some 5 Afterimage Tag Techniques (T15.3)
degrees, rendering the remaining head turn cos- The use of afterimages s a practical training tech-
metically acceptable. This amount of prism can nique for improving steadiness of fixation and
440 Chapter15
X x
X x x *x* x
x x * x x using a Synoptophore for congenital nystagmus
x X X X
XX Y* 0
00o0 cases. He presented a series of 54 patients showing
XX Oo O O O
OOoO O
O 0 00_
O O O significant improvements in nystagmus control,
o o visual acuity, and stereopsis. This clinical series
O 0 0
included successful treatment of patients ranging
in age from 6 to 49 years. Another encouraging
result was the relatively small number of training
sessions (average of 12) needed to achieve the
optimum response. All patients applying for treat-
ment were accepted but for those individuis who
A
A had poor concentration or were epileptic (and pos-
^ A A
V A sibly sensitive to flashing lights).
A The therapy method consists of monocularly
A A A stimulating each eye in turn, 15-20 minutes per
A A session, using a Synoptophore flashing at a fre-
- A ; quency between 3 and 4 Hz. This frequency was
A A A A
chosen because of success in cases of amblyopia,
suppression, and ARC. Mallett24 noted that binocu-
FIGURE 15-6Example of a Synoptophore slide that can be used in
lar stimulation may be even more effective, but this
ntermittent photic stimulation. The slide s covered with a red filter, was not attempted. The patients' task was to iden-
and the patient s instructed to count the critical details (e.g., number tify and count detailed targets on slides, such as
of triangles). (Modified from RFJ Mallett. The treatment of congenital
groups of dots or triangles (Figure 15-6). All slides
idiopathic nystagmus by ntermittent photic stimulation. Ophthalmc
PhysiolOpt. 1983;3:341-356.) had a red-filter background because that tends to
promote foveal fixation in amblyopic and nystag-
mus cases.23-25 Therapy sessions lasted 30-40 min-
utes. Patients initially experienced considerable
reducing a compensatory head turn. The afterim- difficulty in moving fixation within patches of
age gives the patient visual feedback regarding the detail but, with practice on a large variety of tar-
intensity of nystagmic oscillations. A binocular gets, precisin of fixation and visual acuity both
afterimage is applied using a strobe flash generator improved. To prevent regression of learned skills,
(see Figure 5-40a) from a distance of approxi- Mallett24 recommended that patients train for an
mately 50 cm while the patient holds fixation as additional six sessions after mximum acuity was
steady as possible at the nuil point, if present. The
attained.
patient observes the movement of the afterimage The results of photic stimulation were consis-
as a blank screen is viewed with a blinking light in tently good with both heterophoric and strabismic
the background to intensify its perception. As patients. Of the 54 patients in this series, only 43%
threshold size targets are gradually introduced into began with visual acuity of 20/40 or better, the cur-
the visual field, the patient attempts consciously to rent standard for obtaining a driver's Tcense; how-
reduce the intensity of the afterimage movements ever, after therapy, 83% met this criterion. At least
and to resolve the detail of the targets. The goal o two lines of acuity improvement could be expected.
this technique is to develop patients' conscious In those tested, contrast sensitivity also improved
control of the nystagmic eye movements so that after treatment sessions. Mallett24 noted that ambly-
they can dampen the oscillations at will, under opic eyes also increased in acuity, which is not sur-
social circumstances, orwhen maximal visual acu- prising because the technique originally was
ity is required.
designed for this anomaly. The amplitude of nystag-
Expanding the nuil regin to the primary position mus diminished appreciably in many patients and
also can be attempted by having patients first adjust was completely neutralized in a few cases. Stereop-
the head posture to reduce the oscillations (the nuil sis was established in several patients previously
position) and then slowly moving the head toward without it and was increased in others.
the primary field of gaze while attempting to main- Little regression of visual acuity was found in
tain the dampened oscillations.23 progress checks. Only approximately 10% of the
patients lost acuity of a Une or more on the Snellen
Intermittent Photic Stimulation (T15.4)
chart; however, this was quickly regained after a
Mallett24 adaptad an amblyopic training technique
few therapy sessions. Although not a panacea for
Chapter 15 441

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

Without Auditory Biofeedback With Auditory Biofeedback

P 6[ 'f^^^^i^^

FIGURE 15-7Control of nystagmus n five


patients using auditory biofeedback. Eye
position (P) and velocity (V) as a function of
time with and without auditory biofeed-
back. Reduction of nystagmus is evident n
each patient with addition of auditory bio-
feedback. (L = leftward eye movements.)
(Reprinted with permission from KJ Ciuf-
freda, SC Goldrich, C Neary. Use of eye
movement auditory biofeedback n the con-
trol of nystagmus. Am J Optom Physiol Opt.
1982;59:396^09.)
5 sec

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

FIGURE 15-9Left hyper deviation of 52A. a. Manifest deviation. b. Patient fusing.

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

6 hours of labor); the full-term child weighed 8 30LET


pounds, 6 cunees at birth. There was fetal distress,
however, due to anoxia. The infant had a ductus
arteriosus shunt, an abnormal connecting tube
between the aorta and a pulmonary artery. This
5LET 50LET
shunt closed by itself within 24 hours. Thereafter,
40LET
the child experienced good health and normal
development until age 2 months, when nystagmus
was first noticed. A left head turn developed at age FIGURE 15-10Noncomitant esotropa with V pattern. (LET = left
esotropa.)
4 months, and a left esotropa was seen at 10
months. The family had no hstory of nystagmus,
strabismus, or severe visin disorders. (20/50), and there was less nystagmus than previ-
Cycloplegic retinoscopy (1% cyclopentolate ously in the left field of gaze. Strabismus surgery
[Cyclogyl]) revealed a small amount of hyperopia: was performed at age 18 monthsa recession-
OD +1.00 DS; OS +0.75 DS. Visual acuity was resection operation of the left eyeresulting in an
assessed by visually evoked potentials and indi- intermittent 12A left esotropa and improved hori-
cated a significant difference between the eyes: OD zontal comitancy. The head turn reduced to
20/55; OS 20/130. A cover test showed the pres- approximately 10 degrees left. Spectacle lenses
enceof an ntermittent, noncomitant, unilateral, left with BO prisms then were prescribed (OD: 3 A
35A esotropa at far and near. The child apparently BO; OS: 6 A BO). These prisms improved the
fused n right gaze and therefore had a habitual 25- child's fusin n the primary position, further
degree left head turn. The noncomitancy pattern reduced the head turn, and dampened the nystag-
suggested a paresis of the LLR, a slight limitation of mus. Although initially resistant to wearing the
abduction of the left eye, and a small V pattern (Fig- prism spectacies, the child eventuaily accepted
ure 15-10). The Bielschowsky head tilt test was neg- them over a 2-month period; the binocular acuity
ative. The nystagmus appeared to be constant, mproved to 20/30.
pendular, and conjgate, with equal amplitude in The patient was scheduled for progress checks
each eye, although t and the frequency varied; every 6 months and was released. The parents
amplitude decreased on convergence and ncreased were pleased with these results: minimal nystag-
in left gaze. No latent component to the nystagmus mus; adequate acuity n each eye, no strabismus in
was seen. The ocular health seemed unremarkable, the primary position, and no apparent head turn.
except that the fund appeared to lack pigment. An This case Ilstrales that binocular therapy can help
electroretinogram was administered to rule out the to reduce congenital nystagmus.
possible etiology of ocular albinism; the results
proved to be negative. The child's disorder was diag-
nosed as efferent congenital nystagmus (possibly
REFERENCES
related to anoxia at the time of birth), LLR paresis,
and amblyopia of the left eye. 1. von Noorden GK. Binocular Vision and Ocular Motility:
Theory and Management of Strabismus, 5th ed. St. Louis:
No spectacles were recommended because of the
Mosby; 1996:419.
nsignificant refractive error. In an attempt to cure 2. Erickson GB, Caloroso EE. Vertical diplopia onset with
the amblyopia, 4 hours per day of direct first-time bifocal. Optom Vis Sci. 1992;69:645-651.
occlusion using a bandage occluder was pre- 3. Wick B. Vision therapy for cyclovertical heterophoria.
scribed. Fortunately, the nystagmus did not Probl Optom. 1992;4:652-666.
worsen with patching. (If latent nystagmus had 4. Iwasaki Y, Wanaka Y, Ikeda N, et al. Treatment and prog
nosis of diplopia. Nipn Canka Gakkai Zasshi Acta Soc
been present, the right eye would have to be Ophthalmol Jap. 1993;97:815-850.
fbgged rather than total ly occluded to promote 5. Rutstein RP. Evaluation and treatment of ncomitant devi-
fixation with the amblyopic eye.) Ocular calis- ations in children. Probl Optom. 1990;2:528-561.
Ihenics were prescribed intermittently to improve 6. Eskridge JB. Persisten! diplopia associated with strabismus
Ae restriction of abduction of the left eye while surgery. Optom Vis Sci. 1993;70:849-853.
7. Boyd TAS, Karas Y, Budd GE, et al. Fixation switch diplo
te right eye was patched. After 2 months of this
pia. Can J Ophthalmol. 1974;9:310-315.
regimen, there was no restriction of abduction, 8. Karas Y, Budd GE, Boyd TAS. Late onset diplopia in child-
acuity of the left eye equaled that of the right hood onset strabismus. J Pediatr Ophthalmol. 1974;11:
135-136.
450 Chapter15

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

Visual Comfort and Performance 452 Plus-Lens Acceptance Training


Aniseikonia 452 Monovision 455 CT16.20) 465
Saccadic Eye Movements 455 Specific Training Techniques 465
General Approaches to Training Accommodative Tromboning
(Steps 1-10) 455 (TI 6.21) 465 Jump Focus
Specific Techniques (T16,1 -T16.12) 457 (T16.22) 465 iens Rock (TI
Picking Up Objects (T16.1) Toothpck in 6.23) 465 Other Considerations
Straw (T16.2) Peg-board Games (T16.3) 466 Vergences 466
WaHFixations(T16.4) Fixations with an Finishing Concepts in Heterophoria 466
Afterimage (T16,5) Continuous Motion Hyperphoria 467 Vertical Step
Tasks (T16.6) Lose Prism Steps (T16.7) Vergence (T16.24) 467 Variations on
Dot-to-dot Games (T16.8) Vertical Vergence Training
FillingOs{T16.9) (T16.25) 468 Cyclophoria
Sequential Fixation Sheets (T16.10) 468 Symptomatic Orthophoria
Sequential Fixation Sheets with Cogni- 469 Stereopsis 469 Vectogran
tive Demands fTl6.11) Stereo Enhancement
Computerized Programs (T16.12) (TI 6.26) 469 Computer
Pursuit Eye Movements 460 General Stereo Enhancement
Approaches to Training (T16.27) 470 Case Examples 470 Case
(Steps 1-13) 460 1; Eye Movement Dysfuncttons 470 Case
Specific Techniques (T16.13-T16.19) 463 2: Accommodative Dysfunctions 472
Automatic Rotating Disks (T16.13) Future Directions in Binocular Vision
Swinging (Marsden) Ball (T16.14) Therapy 473 Vision and Reading 473
Penlight Pursuits (T16.15) Pie-Pan Visagraph Testing of Reading Eye
Pursuits (T16.16) Flashiight Spot Chasing Movements 474
(TI 6.17) Minivectograms and Interpretation and Management 476
Minitranaglyphs Efficient Reader Profile 476 *
(T16.18) Inefficient Reader Profile 477 Dyslexic
Computerized Pursuits (TI 6.19) Reader Profile 4^8 Visual Sklls
Accommodation 462 General Training Deficiency ProMe 479 Computers and
Approaches (Steps 1-8) Visual Ski lis Efficiency 479 Sports Vision
462 481 Comments on Health Care 483
ptica! Management 464 Plus-
Lens Additions 464
452 Chapter16

VISUAL COMFORT but reduce their work output. Others rightfully


AND PERFORMANCE complain to their eye doctor who, it is hoped, can
prescribe appropriate visin therapy to ameliorate
Vision efficiency s a modern concept. This con- such patients' signs and symptoms of dysfunction.
cept, however, contines to be rrelevant to the Vision therapy considerations discussed in this
majority of people subsisting in a third-world agrar- chapter are appropriate for those patients who
ian culture. The level of visual requirements for the have specific skill deficiencies, with associated
farmer guiding a water buffalo is not as high as that signs and symptoms, and for those individuis
of a technical worker who is expected to succeed seeking enhancement of their visual performance
in 12-20 years of formal education, which is in school, work, and play. These therapies are also
merely a precursor to an eventual occupation. appropriate for strabismic patients who have made
Vision efficiency refers to ocular comfort with high progress in a visin therapy program but have not
performance over time. Many workers who must yet achieved the highest level of visin efficiency.
look at a computer display for 7 or 8 hours daily
experience severe symptoms of ocular discomfort.
The causes of these disturbing symptoms may be
binocular anomalies, such as poor vergence or
ANISEIKONIA
accommodative skills, which are intensified if there Aniseikonia is an often overlooked condition that
is a mismatch between that individuaos particular is a barrier to efficient binocular visin. Unex-
oculomotor physiology and psychological disposi- plained binocular symptoms may be due to
tion and the job's visin requirements. This chapter aniseikonia. This condition s one in which the
is based on the premise that inefficient visual skills ocular image size of one eye s different from that
can be remedied when it is in a patient's interest to of the other. This problem is often produced by
do so. Over the years, we have seen an ncreasing anisometropic corrective lenses f the power differ-
number of office workers, computer operators, ence between the two eyes is significantly large.
machinists, lawyers, athletes, and others seeking Contact lenses may be a remedy in cettain cases,
improvement in visual comfort and performance. particularly if the anisometropia s refractive,
Unless world culture takes an unexpected turn in meaning that the corneal curvatures of each eye
its evolution, this trend toward the necessity for are greatly different. If, however, the anisometropia
higher visin efficiency will continu to accelerate. is due to differences in eyeball length (axial aniso-
The rise in world literacy s a fundamental part of metropia), a spectacle lens correction may be pref-
cultural and economic development. The print-ng erable to contact lenses. There are exceptions,
press, invented approximately 400 years ago, however, that show inconsistencies in Knapp's
rendered possible the distribution of books to the law.3 This may be due to the fact that aniseikonia
public at large. Now we find that there are many can result from a difference in distribution of the
ocular conditions that compromise reading com- retinal elements and from a difference n the size
fort and performance. Clinical experience and of the dioptric images formed on the retinas. Clini-
studies have shown a higher prevalence of certain cians must, therefore, evalate each patient and
visual problems among poor readers as compared not always adhere strictly to Knapp's law. In some
with skilled readers. Uncorrected hyperopia and cases of axial anisometropia, contact lenses may
anisometropia, excessive exophoria and fusional be the preferred prescription. When the difference
vergence deficiency, hyperphoria, and accommo- in ocular image size is very small (e.g., less than
dative infacility have all been implicated by associ- 1%), symptoms usually are not produced. As the
ation.1 The computer age has burgeoned into mass size difference becomes greater, symptoms may
markets during the last few decades, and this genie result. If the aniseikonia is greater than 5%, this
will not be put back into the bottle. A large number obstacle to fusin may render it impossible for
of computer operators show deficiencies in ver- affected individuis to have central fusin.
gence and accommodation over time. 2 Many Many of the symptoms reported by patients
symptomatic individuis respond to increasing with aniseikonia do not differ significantly from
visual requirements in inefficient ways. Some lose symptoms of ametropia, heterophoria, and inter-
interest and avoid the noxious stimulus altogether, mittent strabismus (e.g., headaches, asthenopia,
whereas many individuis tolrate the discomfort reading difficulties, and diplopia). 4 Other symp-
Chapter16 453

toms associated with aniseikonia are photopho-


bia, nausea, nervousness, dizziness, vrtigo, and
general fatigue. When ametropia and binocular MADDOX ROD
FILTER
anomalies are eliminated, the persistence of such
symptoms may indcate aniseikonia, providing
ihat such patents are in sound physical and men-
tal health. Anseikonic symptoms are generally
long-standing and are not relieved by conven-
tional prescription lenses or visin training. OS. OD
However, the American Optical Space Eikonome-r is
no longer avalable for the precise measurement | o
the magnitude of anisekonia. Other methods
mam for nvolved clinicians. Clinicians can esti-
the magntude of aniseikonia from the refractive tion
5
of anisometropia. Ogle suggested that ?konia of
1.5-2.0% is induced by every dopter i of
ansometropa that s corrected wth spectacle s.
Others have disagreed with Ogle's estmate
67
indcate that 1% per diopter s a more realistic ?. '
Most clnicans use 1 % per diopter as a cln-gudelne
(a so-called rule of thumb). Lubkn et L* reported the
lmitatons of such estimatons. The other method s
direct comparison of the images. There are
several ways in which can be dissociated for
drect comparison: cal prism dssociaton,
stereograms, and vec-jhic methods. W e
recommend using a Mad-rod and two penlghts
(Figure 16-1 a). The are held b y the clinic an,
one above the (separation of 15-20 cm), and the FIGURE 16-1Direct method to detect aniseikonia. a. Diagram
patient fix-,the lghts from a distance of showing the right eye looking through a Maddox rod and the left eye
seeing the penlights. b. Patient's perception if there is no aniseikonia.
approxmately 2 .The Maddox rod s orented with c. Perception if there s aniseikonia. (O.D. = oculus dexter; O.S. =
ts axis at 90 s, so the patent should see two oculus sinister.)
horizontal ; with that eye. The other eye does not
have a j x rod bef or e t but lo ok s dir ec tl y at th e
If there s no aniseikonia, the patient should :the comparisons. Our experience with the NAT is that
streaks going through the lights (see Fig-16-1 b). If validity is sometimes inconsistent with a Space
there s a significan! degree of skonia, the Eikonometer. However, we believe t s a good
distance between the streaks will fferent from the screening instrument, and t may be useful n pre-
distance between the lights gure 16-1c). Iseikonic- scribing lenses to compnsate for aniseikonia. The
sized lenses are intro-before each eye n an correction of overall, meridional, or compound
attempt to equalize fsize of ocular images n the (both types of) aniseikonia s accomplished by
vertical meridian. (test other meridians, the magnifying the smaller image n the appropriate
orientation of lights the Maddox rod are meridians until a reasonable size match for a
rotated by the same it to axes of 180, 45, and patient's eyes s achieved, which is the tentative
135 degrees. Any ital or vertical phoria or lens prescription. Overall magnification trial lenses
tropia, however, be neutral ized with a prism can be used to measure seprate meridians.
1 9
before the konic measurement can be made. New Kleinstein suggested using custom-made trial
Aniseikonia Test (NAT) of Awaya (Han-r Tokyo) is lenses. Calculations for glass and plstic lenses were
composed of sets of red and green :les that are performed by Dr. Richard Hemenger of the Southern
anaglyphically viewed for size California College of Optometry, for optical parame-
ters of an afocal aniseikonic trial lens set (Tables 16-1
and 16-2). Local optical laboratories can fabrcate a
tral lens set such as this, ether in glass or plstic.
454 Chapter16

TABLE 16-1. Magnification of Trial Lenses Based on


Curvature and Thickness of Crown Glass Lenses with TABLE 16-2. Magnification of Tra/ Lenses Based on
Index ofRefraction of Approximately 1.53 Curvatura and Thickness of Plstic Lenses (CR-39)

with Index ofRefraction of Approximately 1.50

Front Back Front Back


Magnifkation Surface Surface Thickness
(%) (D) 0 (mm) Magnification Surface Surface Thickness
<%>. (D> (0) (mm)
1 +5,00 -5.00 2,2
1 +5.00 -5.00 2.2
2 +11.25 -11.50 2.7
3 +12.00 -12.37 3.7 2. . +7.50 -7.62 3.9
4 +12.00 -12.50 4.9 3 +9,00 -9.25 4.9
5 +12.00 -12.62 6.1 4 +10,00 -10,37 5.8
7 +16.50 -17.62 6.1 5 +12.50 -13.12 5.7
9 +20,75 -22.62 6.1 j +16.3? -17.50 6.0
11 +25.00 -27.75 6.1 9 +20.62 -22.50 6.0
11 +24.75 -27.50 6.0

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

sive sequence from easiest to most difficult. Most


TABLE16-3. General Training Approaches for of these can be performed at home, and the princi-
Saccadic Eye Movement Dysfuncton pies listed in Table 16-3 can be applied.

1. Ensure good position maintenance (steady f ixa-


Step 3
tion on a stationary target). Step 3 introduces the element of speed for various
2. Proceed from gross (large) saccades to fine (small) sizes of saccades. A useful instrument for improv-
saccades (as n readlng). ing the speed of gross saccades is the Wayne Sac-
3. Proceed from slow to fast (tming of several cadic Fixator (Figure 16-2). Most patients enjoy
cycles). working on this electronic instrument, which has
4. Develop good eye-hand coordination during sac- an automatic timer. The Wayne Saccadic Fixator is
cadic demands, and then proceed without hand as similar to the more advanced DynaVision 2000
support (e.g., no finger reading). electronic fixation instrument (see Figure 10-8).
5. Train until each eye has equal skills. Later, emphasis can be placed on increased speed
6. Proceed from monocular (duction) to binocular for fine saccades, as in timing activities using Ann
(versin) saccades. Arbor Tracking booklets (see Figure 10-12).
7. Elimnate any head movement.
8. Introduce motor sequencing with metronome Step 4
(auditory-visual integration) and ensure good left-
Good eye-hand coordination during saccadic
to-right sequencing of saccades, as in reading the
tasks should be ensured. The goal in this phase,
English language.
once good eye-hand coordination s achieved, is
9. Develop automated saccades. (Simple cognitive
demands during saccades should not have an
to discontinu the hand as a support. (It s very
adverse effect on the quality of eye movements.) interesting to see how the finger s used, even by
10. Elimnate (f possible) any significant overshoots, adults, as a support under certain stressful situa-
undershoots, regressions, or inefficient return tions, such as when reading a legal document on
sweeps. which a signature s required.) Usually, if they can
point to the numbers, letters, or words, patients
with poor saccadic ability perform better than f
they have to lcate them accurately by visual
each eye. Position maintenance (fixation) probably means alone. As it s inefficient to point to each
involves all four of the eye movement systems: sac- fixated object of regard, the hand-finger support
cades, pursuits, vergences, and nonoptic reflexes mus be discouraged as soon as is possible n the
(e.g., vestibular). If fixation ability s reasonably therapy program.
good, the therapy can move on to step 2 for sac-
cadic training. In cases of amblyopia, this anomaly
Step 5
would have to be treated initially (see Chapter 10).
Saccadic training should be given for each eye sep-
As s customary, binocular saccadic training would
arately until performance s equal or approximately
follow only after the mprovement of visual acuity.
so. This goal s not always possible to achieve, but
an attempt should be made to reach it.
Step 2
In step 2, the patient practices accuracy of sac-
Step 6
cades, progressing from large to small eye move-
When the eyes are approximately equal in ability,
ments. The large saccades are mostly voluntary
training can proceed to binocular saccadic eye
and can general ly be improved with concentrated
effort by the patient. Fine saccades, as used in movements (versions). Steps 1-4 should be repeated
reading, tend to be reflexive; they are more diffi- under binocular conditions.
cult to train initially. Training techniques would go,
for example, from the patient practicing wall fixa- Step 7
tions (gross saccades) to working with Ann Arbor The purpose of the seventh step n therapy is
(Michigan) Tracking materials (fine saccades; see elimination of any unnecessary head movements
T10.7 in Chapter 10). Table 16-4 lists some specific during fine to moderately large saccades. The
training techniques that are arranged in a progres- finely tuned extraocular muscles are much more
Chapter16 457

TABLE16-4. Specific Techniques for Saccadic Dysfunction

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

larly be used. The Lite-Brite is relatively inexpensive


and suitable for home training of children.

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.

speed is ncreased from slow to fast. One good Step 10


method for building accurate rhythmic saccades s The final step n this sequence is the finishing pro-
to combine wall fixations with a foveal afterimage. cess in which significant overshoots, undershoots,
Patients move the afterimage by fixating different or regressions are eliminated. If there are neurologic
objects on a wall to the beat of a metronome (see soft signs, affected patients may not be completely
Chapter 10 regarding foveal tags with afterimages). able to overeme these inaccurate eye movements.
Such toys as the Lite-Brite (Figure 16-3) can simi- However, we have been amazed at the progress

FIGURE 16-3Lite-Brite game for sac-


cadic eye movement training.
Chapter16 459

RCURE 16-4Continuous motion game.


TViis can be custom-made and varied for
therapy. The patient s nstructed to draw a
continuous une to connect the numbers in
proper sequence.

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

FIGURE 16-5Example of Rosner Test of


Visual Analysis Skills (IVAS) training.
(Reprinted with permission from J Rosner.
Helping Children Overeme Learning Diff-
culties. New York: Walker and Co; 1993.)

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

possible to follow the target, whether it be a swing- Step 6


ing Marsden ball, a moving hand-held penlight, or Smooth movements can be solicited by giving
an afterimage on the hubcap of a passing car. Voli- patients feedback regarding the accuracy of pur-
tion (and attention) are important in the remaining suits. Two types of feedback are available. The
steps, particularly n controlling head movement. therapist can directly observe patients' pursuit
movements and report inaccuracies as they occur.
Step 3 Subjectively, patients can observe pursuit inaccu-
In step 3, eye-hand coordinaron is trained. Patients racies with a foveal afterimage tag. Step 6 s one of
should practice correctly pointing to the moving tar- the most effective n building accurate pursuits.
get. The act of pointing provides visual-kinesthetic Some form of feedback is critical n all stages of
support for proper eye fixation and tracking. Many visin therapy.
of the techniques for amblyopia therapy presented If jerky pursuits are due to functional causes,
n Chapter 10 apply here. In time, after good eye- such as attention problems, the prognosis for
hand coordination is achieved, pointing should be achieving smoothness is good. We consider the
discontinued so that pursuits can be practiced and prognosis for maturational delays in fine motor
mproved without this support. coordination to be fair; training can improve pur-
Additional eye-hand training may be introduced suit movements in most of these cases. Nystagmus
for variety. One technique of which most children and other neurologic disorders, however, present a
are fond is the so-called talking pen (see Figure formidable obstacle in this regard. Nevertheless,
10-10). The pen has an infrared light sensor n its tip. we have seen some patients with nystagmus
When the tip of the pen is exactly on a dark line, no improve their pursuits, particularly after successful
sound is emitted; however, when the tip falls off the results with accommodation and vergence therapy.
dark line onto a bright portion of the paper, the pen
emits a buzzing sound. The sound is louder and Step 7
higher in pitch as the tip moves from a darker to In step 7, patients must become aware of unneces-
lighter rea. Later, when auditory feedback is not sary head movements during pursuits and exert
essential, the tracing pursuits can be strictly visual. voluntary control to stop such movements. Positive
feedback to such patients is important. A conve-
Step 4 nient adjunct n therapy is to have patients "wear a
Step 4 involves progressing from small to large book" on their head. When it falls off, they know
excursions, as large as possible. (Note that the pro- that head motion was the cause.
gression in saccadic therapy is different; the training
proceeds from gross to fine movements, because Step 8
larger saccades are easier to control than are smaller If monocular training of each eye has been effective
saccades, such as reading saccades.) Pursuit training up to this point, the pursuit skill of the right and left
begins within a range where success comes easily, eyes should be approximately the same. If not, fur-
then ends with large excursions. The range of move- ther training for the deficient eye is indicated. On
ment is naturally limited, being smaller for up-gaze occasion, it is impossible to achieve equality.
(approximately 30 degrees) as compared with other
directions. The rotation range with a swinging Mars- Step 9
den ball as a target, for example, can be ncreased Binocular pursuits should be trained to the same
by simply having patients move closer to the target. level as monocular pursuits. Usually, patients have
no problem n making the transition from ductions
Step 5 to versions. An exception occurs when there is a
Speed is emphasized in step 5. Fast pursuits are nor- vergence anomaly. For example, intermittent exo-
mally more difficult than are slow pursuits. There- tropic patients may have difficulty n proceeding
fore, it is best to start pursuit training at a slow speed from monocular to binocular pursuit training
within patients' ability to perform and progressively because of the voluntary effort required to main-
to ncrease the target speed. On a training task, such tain bifixation on the target. Considerable ver-
as a buzzing pen, patients are encouraged to finish gence and binocular pursuit training may be
the task more quickly while mamtaining accuracy. needed in this step.
462 Chapter16

Step 10 while balancing a book on the top of the head,


In step 10, cognitive demands are introduced, pro- counting backward by threes from 100, balancing
A
ceeding from simple to complex. Some adults can on the balance board, and wearing 15 BO prisms.
calclate numbers while maintaining fixation on a The purpose of such combinations is to increase
moving target. However, such complex tasks stress to a mximum. This level of training may be
exceed what is normally expected of younger particularly useful for certain patients who require
patients in visin therapy. Cognitive demands for a high standard of performance in athletic events.
children must be appropriate to their ability. Chil-
dren can be asked, for example, to sing a song, Specific Techniques
count from 1 to 10, or state the ames of friends (T16.13-T16.19)
and relatives.
Most of the foregoing general approaches (usted in
Table 16-5) can be applied to the seven specific
Step 11 techniques listed in Table 16-6. An automatic rotat-
Step 11 focuses on integrating pursuit eye move- ing device, such as a Bernell Rotator (see Figure 2-
ments with general body posture, movements, and 13) can serve as an example. Once steady position
balance. The vestbulo-ocular response (VOR) sys- maintenance of a stationary target is estab-lished,
tem nvolves the otolith organs, semicircular cais, patients are asked to follow a target on the rotating
and neck receptors. This system integrales eye and disk. Such patients may have to resort to voluntary
body movements and is increasingly involved when saccades before reflexive pursuits can be made to
individuis change posture requiring dynamic bal- follow the moving target. They can point to the
ance, as in skng. This is so when patients are asked target for eye-hand support. Next, the size of
to stand on a balance board or to move forward and excursions can be ncreased by moving patients
backward on a walking rail while performing accu- closer to the instrument. The speed of the target
rate pursuit eye movements. At first, there is a stimu- can be increased. Accuracy and smoothness of
lus overloading for such patients; they will not be pursuits are emphasized. It is important to give
able to balance and maintain good pursuit eye patients adequate feedback regarding how well
movements as well as when in a sitting position. If they are doing in all steps, but particularly when
there are no neurologic defects in the VOR and pur- working on accuracy. Also, they should not make
suit systems, however, most patients can eventual ly unnecessary head movements during pursuit train-
learn to cope with these demands and perform pur- ing. Each eye is trained ndependently until perfor-
suits accurately. mance is equal. Binocular pursuits then are trained.
Cognitive demands (e.g., counting numbers aloud
Step 12 while doing pursuits) are presented. Affected
A stimulus "overloading" can also be accom - patients stand up and balance to help intgrate
plished by bringing in the vergence system, as is pursuits with the VOR system. Prismatic demands
accomplished n step 12. Base-out (BO) lose for fusional vergences are ntroduced. Higher lev-
prisms can be placed before patients' eyes to crate is of performance can be achieved by combining
a convergence demand while the patients view a the aforementioned steps in various ways.
moving target (e.g., a hand-held moving penlight).
Conversely, a divergence demand can be created
by placing base-in (Bl) lose prisms before patients' ACCOMMODATION
eyes. If they can overeme the prismatic demand
In this section, visin therapy is discussed for
and continu to perform pursuits well, patients are
accommodative excess, insufficiency, infacility, lag,
ready to proceed to more stressful demands.
and poor stamina. These dysfunctions and their
diagnoses are discussed in detail in Chapter 2.
Step 13
Increased stimulus overloading can be accom -
plished in many ways and is the task performed n General Training Approaches
step 13. There are many permutations and varia- Eight steps of active visin training are listed here and
tions using the previous 12 steps. For example, in Table 16-7 in our recommended sequential order
patients may be asked to follow a moving target for the improvement of accommodative functions.
Chapter16 463

TABLE16-6. Specific Vision Training Techniques for Pursuits

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

FIGURE 16-6Minitranaglyph. The


patient wears red and green filters while
trying to fuse split targets with variable
demands on fusional vergence. The
device can be moved into various fields
of gaze for pursuit eye movements
simultaneously with motor fusin and
appreciation of stereopsis. This is an
excellent home training technique.

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

RCURE 16-8Eye movement testing results befare visin therapy.


FIGURE 16-9Example of starlike configuraron of rows of letters for
a. Position maintenance. b. Gross saccades. c. Fine saccades on card
saccadic training (also useful as a target for near-far-near accommoda-
with five dots per row (see Figure 2-3).
tive and other visin training).

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

aches or pain n the eye. She reported "notic-


ing a greatly increased reading speed." O:
Phorometry indicated orthophoria at far and 5A
exophoria at near. Bl was A/5/4 at far and 20/
24/18 at near. BO was 14/24/12 at far and 187
24/18 at near. Accommodative amplitude was
11.00 D OD and 11.00 D OS. On Keystone
Eccentric Circles, 55A BO chiastopic and 37A
Bl orthopic fusin were achieved. The Eye-Trac
showed improvement n fixation and eye
movements with fewer regressions during sac-
cades and better return sweeps (Figure 16-10).
A: All subjective and objective problems were
abated.
P:The patient was dismissed for 6 months and
put on a maintenance program with the fol-
lowing home visin training prescription: pen-
cil push-ups, monocular and binocular, for 5
FIGURE 16-10Eye movement testing results after visin therapy. minutes weekly; binocular pencil saccades
a. Position maintenance. b. Gross saccades. c. Fine saccades. (two pencils) for 5 minutes per week; and Key-
stone Eccentric Circles for orthopic-chias-
topic vergence rock with fixation shifts to a
astopic fusin at near with jump vergences to the farpoint Hart Chart for 5 minutes per week.
Hart Chart for saccadic training); (2) Michigan The patient was advised to have a progress
tracking for saccadic training for 5 minutes per evaluation in 6 months.
day; and (3) circling vowels in newspaper print
along with "dive-bombing" them with a pend
from above (i.e., fast pointing). Case 2: Accommodative
The patient reported on the fourth visit that she Dysfunctions
noticed better performance during home training. This patient in this case had accommodative insuffi-
Office training included saccadic and fusional ciency and infacility.27 A 30-year-old female college
vergence training. She was able to fuse with clear- student presented with frequent headaches and
ness and singleness on the Aperture-Rule Trainer burning of the eyes after an hour of concentrated
more than 30A BO and 22A B!. The patient showed reading. She would sometimes becorne dizzy when
excellent compliance with home and office train- shifting focus abruptly from the chalkboard to her
ing and was highly motivated. Home training was notebook. Onset of symptoms coincided with
prescribed as follows: (1) orthopic and chiastopic entrance into college 6 months previously. Her his-
fusin for vergence rock in free space, 5 minutes tory was unremarkable, and the patient had never
per day (to improve vergence ranges and facility); worn any spectacle or contact lenses.
(2) combination of the first technique with shifts There was no significant refractive error and
of fixation to a farpoint Hart Chart 5 minutes per unaided visual acuities were 20/15 (6/4.5) each eye.
day; (3) combination of the first technique with The patient had 1A exophoria at far and 5A exophoria
Landolt Cand starlike charts 5 minutes per day; and at near. Fusional convergence at far was slightly
(4) Michigan tracking activities 5 minutes per day. restricted (4/12/10). The NPC was normal (7 cm).
The fifth visit was 3 weeks later. Using the SOAP Monocular accommodative amplitude, however,
format (subjective, objective, analysis, plan), the was markedly reduced for her age (6 D). Also,
results of this progress evaluation visit were as accommodative facility using +1.50-D flipper
follows: lenses was only 2 cycles in a period of 90 seconds.
A home visin training program of 20 minutes
S: There were no subjective complaints. The per day was initiated to build accommodative facil-
patient was doing a great deal of reading in ity, working on speed, accuracy, and sustaining
college and was not experiencing any head- ability. Prescribed visin training included pencil
Chapter16 473

push-ups, jump vergences, accommodative lens


rock with flippers, Brock string and beads, and
monocular jump focusing. The patient used home
instruction sheets for each of these techniques and
aithfully followed the program for 5 weeks. She
returned once weekly for a progress check. The
patient's accommodative amplitude and facility
improved quickly to almost normal levis after only
2 weeks of training. By week 3, the lens flipper rate
was 25 cycles in 90 seconds. (Figure 16-11 shows
increased speed.) Reduction of symptoms paral-
leled the increase n skills. Headaches, dizziness,
and asthenopia with reading decreased noticeably
after week 2 of training; these symptoms were com-
pletely eliminated by the fifth week.
Ratients with accommodative insufficiency and FIGURE 16-11Graphical representaron showing improvement in
accommodative facility with visin training.
infacility often respond quickly and dramatically to
ashort-term visin training program. If they do not,
Ihen other possible causes should be reinvesti-
gated. Prescribing plus-add reading lenses also abridged copy of this statement.) In contrast, a posi-
often helps to relieve symptoms. tion policy statement from the American Academy
of Pediatrics, American Academy of Ophthalmol-
ogy, and American Association for Pediatric Oph-
FUTURE DIRECTIONS IN thalmology and Strabismus29 asserted that ". . . the
BINOCULAR VISION THERAPY majority of children and adults with reading difficul-
Binocular anomalies, particularly heterophoria and ties experience a variety of problems with language
visin efficiency dysfunctions, can cause visual dis- that stem from altered brain function and that such
comfort and inefficiency at school, work, and play. difficulties are not caused by altered visual func-
In the last three decades, we have seen a rising tion." These groups further stated, "No scientific evi-
number of heterophoric and visin efficiency dence supports claims that the academic abilities of
patients who need and want visin therapy. The children with learning disabilities can be improved
prevalence of strabismus and amblyopia probably with treatments that are based on ... visual training,
will decline because of early detection n infants including muscle exercises, ocular pursuit, tracking
and young children and, consequently, timely and exercises, or 'training' glasses.. . ,"29
appropriate ntervention with visin therapy. We There may be some merit in these assertions: For
believe, however, that there will be an ever- example, dyslexia may, n part, be due to "altered
increasing demand for binocular visin therapy brain function" and not necessarily caused by
seivices. At least three cultural movements provide "altered visual function." The discussions on visin
ie mpetus: (1) a movement toward lifelong edu- and learning, including reading, in this text, how-
eation; (2) the emergence of high-tech industries as ever, provide evidence to contradict most of the
tte basis of modern economies; and (3) a move- assertions made by these professional organiza-
ment toward universal physical fitness with increas- tions and highlight a lack of understanding on the
ng participation in sports. part of the authors of the policy statement. We
believe that the discussions n this text provide evi-
dence that verifies the relation of visin and learn-
[Vision and Reading ing, ncluding reading, as well as the positive
[One recurring theme n this text has been the rela- effects of visin therapy.
Ition between binocular visin symptoms and read- In their investigaron of this issue, Grisham et al.30
ig problems. A special commentary by optometrists reported that poor readers (defined by standardized
fcnt support to the concept that visin problems are testing) generally experience more visual symptoms
riated to learning problems, n which reading dys- than do good readers. They also found a low, but
^fanction is ncluded. 28 (See Appendix A for an significant, correlation between reading achieve-
474 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

Reading Profile Visagraph


Grade 1 23 4 5 6 7 8 9 101112131415161718

Grade/Goal 3ft Right Norms i i


Fixations/IOOwords 2 11 206 lab
r*x
Regressions/100 words Av. Span of 29 33 35 *

Recognition (words) 0. Av. Duration ^^


of Fixation (sec) 0. 28 0.29 0.28
~j ^r
Rate with Comprehension (words/min)
Relative Efficiency Grade Leve!
Equivalen!
Oirectional Attack Rate adj. for
Rereading (words/min) Comprehension
Questions Corred Cross Correlation
:

, | 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 :

Text information Countable part statistics


Filename : C:\VISA\TEXTS\amer_eng\T--2-28.TXT Tille : No of unes : 9 Noof words:
The Largest Bird 2-28 Answers : YYYNYYYNNN 63 ) Av. word length : 4.3
Noof questions : 1( Norms used : TAYLOR.NOR 3
Correct answers : I

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

the tem that describes the child's school or home behavior.

1Always; 2Frequently; 3Occasionally; 4Rarely; 5Never; 6Unknown

____ Hyperactive
____ Easily distracted
____ Short attention span
____ Easily frustrated
____ Impulsive
____ Easily fatigued
____ Poor ability to organize work
____ Indistinct speech
____ Awkward or clumsy
____ Poor peer group relationships
____ Behavior problems
____ Emotional problems
____ Confusin after a series of verbal instructions
____ Variable school performance (from hour to hour or day to day)
____ Reverses letters, words, or numbers in reading
____ Reverses letters, words, or numbers in writing
____ Shows confusin about right, left, or other directional orientations

FIGURE 16-13Questionnaire screener for learning problems. (Modified from Lee S, Grisham JD. Establishing history tems for learning disabled
children. O.D. Thesis, University of California, Berkeley, 1975.)

3. The grade-level equivalent, an overall 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.

Inefficient Reader Profile


An inefficient reading strategy is indicated under
the following conditions:
1. The grade-level passage needed for success-
ful testing is more than 1 year below the
school-grade placement. The fluency level is
determinad prior to Visagraph testing by hav-
ng the patient read aloud a grade-level selec-
grade-level passage s chosen until fluency is
demonstrated. An altrnate selection at the fluency
level then s chosen for Visagraph testing, and the
patient reads this silently. 2. The reading rate or
grade-level equivalent s more than 1 year lower
than the patient's grade placement. These patients
often have a profile that is consistently, across-the-
board lower than their grade placement, which may
be due to reading habits that have not changed
with experience. The patient reads successfully but
slowly. Some subvocalize (subcortical vocalizaron)
when reading, which limits reading speed. These
patients do not have a history of signs and symptoms
that indcate a learning disability (Figure 16-13; see
also Appendix B). There is no evidence of
476 Chapter16

eyes are trackmg in tndem or are out o syn-


makes. \n most cases, regressions are made to
chrony. A correlation of 0.950 or higher indicates
search for word or sentence meaning that has been
good teammg o the eyes. Poor teammg m the eye
missed dunng orward \xat\ons. Some regress\ons
movement record can be caused by trackmg, dys-
are normal and expected at a\\ \eve\s o reading
unctions, ocusmg prob\ems, and lapses o binocular
expertise, but they genera\\y decrease with grade
level and reading experience. fusin when the eyes under- or overconverge.
Average span of recognition refers to the num- Saccades n return sweeps are evaluated by
ber of words or word-parts perceived on average assessing the manner in whch saccades are made.
during a fixation pause during reading. This might When the eyes track from the end of one Une to
the beginning of another line, ths return sweep
be thought of as the size of a perceptual "window,"
should be completed in one or two eye move-
which represents a limit on how much information
ments. If 10 lines were recorded, then up to 20
can be processed during fixations. Students n the
first grade generally take n less than half a word at saccades n return sweeps may be normal. How-
ever, to diagnose trackng problems, the eye move-
a time; however, by snior year in high school, stu-
ment recording needs to be nspected directly to
dents perceive slightly more than a whole word.
determine exactly how these movements were
The average span of recognition is calculated by
dividing the number of words in a passage by the made. Return sweeps are efficent if the patient fix-
number of fixations made by the reader. Knowl- ates on the first or second words in the next I me.
However, they are considered inefficient, for
edge of one variable allows one simply to calc-
late the other. example, f the patient simply drops the eyes
Average duration offixation refers to the amount below to the next line and then makes the return
sweep, or if the return fixation lands near the mid-dle
of time the reader's eyes pause during a fixation.
of the next Une.
This ndex can be thought of as the average cogni-
The anomalies ndex represents the number of
tive processing time during each fixation. This
ndex s fairly stable with age; it starts at approxi- times that the eyes were not n perfect synchrony
n an eye movement reading record (e.g., when
mately one-third of a second durng the first grade
and decreases to only one-fourth second by high there s a blink of one eye or a lapse in the ver-
school. Ths means that the eyes typically pause for gence eye position).
information processing between three and four
times per second during reading.
Rate with comprehension refers to reading speed
Interpretation and Management
as measured in words per minute. This ndex is well- Four general profiles are suggested for analysis of
known and is reported n many standardized tests of reading performance based on the Visagraph
reading performance. It must be remembered, how- results, the VSE examination, and developmental
ever, that this rate is determined for a particular type history.
of reading. The student must demnstrate at least
70% comprehension on the test questions. Reading Effcient Reader Profile
rates vary considerably depending on a student's On nspection of the Visagraph readng profile, the
reading strategy (i.e., fast for skmming and slow for clincian can conclude that the patent has demon-
reflective, analytic readng). strated an efficent reading strategy if the followng
Relative efficiency and grade-level equivalent requrements are met:
calculated ndices indcate a student's overall rela-
tive reading efficiency for the level of material 1. There has been acceptable comprehension
read: relative efficency = (reading rate/fixations on a grade-level passage (i.e., at least 70%
per 100 words) + regressions per 100 words (RE = correct answers). (If a student s enterng
[RR/FixTOO] + Reg 00). Therefore, reading effi- the third grade n school or has been
ciency with comprehension increases with faster enrolled for less than half of an academic
reading rates and decreases with more fixations year, for example, a second-grade level
and regressions. passage should be used.)
Other ndices that often gve indcatons of eye 2. The reading rate in words per minute is at
coordinaron and movement dysfunctions are as least within one grade level of the school
follows: Cross-correlation asks whether the two grade level or faster.
Chapter16 477

Behaviors: Please rate the child on thefollowing tems. Place a number in the blank to the left of

the tem that describes the child's school or home behavior.

1Always; 2Frequently; 3Occasionally; 4Rarely; 5Never; 6Unknown

____ 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

perceptual mmaturity, and patients have 1. Crade-level equivalent (i.e., a general


learned grade-appropriate sight words. There ndex of reading effciency) is more than 1
may be, however, some degree of attention year below the grade placement.
dficit hyperactivity disorder (or attention df- 2. Regressive eye movements of al I fxations
icit disorder that makes difficult persistence in (.e., directional attack) total 20% or higher.
the reading act. These are patients who usu- The word or phrase was not decoded prop-
ally can respond quickly and completely to erly on first nspection, and the patient
proper remediation. needed to take another or longer look at it.
3. The average duration of fixaton is excep-
Taylor Associates produces software products tionally extended in relation to the expected
that often improve reading efficiency in the latter duration and to other profile features. This
cases. These products are also available from the finding may indcate that the average cogni-
Berneli Corporation. One of the most effective we tive processing time for decoding s pro-
have used s the Fluency in Reading CD-ROM for longed, whch s one of the characterstics
the PC. It can be distributed only by an eye care of dyslexia. One must be careful here to
practitioner on an individual basis, because the inspect the readng graph tself before
reading skills it teaches are closely ntegrated with reaching this conclusin. If a patent s
visual and perceptual skills. The program s com- given text wth words not n his or her sght-
posed of three modes: Perceptual accuracy and word vocabulary, fxatons may be pro-
visin efficiency can be trained n a sean mode to longed for those words, thereby spuriously
enhance tracking speed and speed of symbol iden- extending the average duraton of fixation.
tification. There s also a flash mode, a tachisto- Occasionally, one finds dyslexics wth a
scopic program, that builds the span of recognition very short average duration of fixation but
(.e., the amount of information that can be pro- an excessive number of fxations per 100
cessed at each fixation). The third mode is a guided words. For example, the reader may fixate
reading program that uses a moving window over each word three times before recognzing it.
grade-appropriate text to ncrease reading speed The overall time per word is therefore
and break inefficient reading habits. In this mode, extended, which is reflected in a slow read
the moving window forces the reader to sean the ing rate.
text faster while comprehension s monitored and 4. Dyslexcs tend to have diffculty in gauging
the speed s adjusted accordingly. Inefficient read- the length of saccades in readng.39 They
ers often respond well to organized remedial read- often show mltiple movements on return
ing programs and individualized instruction by sweeps to get to the beginning of the next
tutors and educational specialists. Some of the line of print accurately. These are known as
many prvate programs that have experience n reverse staircase eye movements and can
improving reading skills are Kumon Reading, be readily identified by the ndex of sac
Hooked on Phonics, and the Reading Carne. cades on return sweeps or on inspection of
the simulation function (showing the fixa
Dyslexic Reader Profile tion pattern) n the men options. Alterna-
Dyslexia comes in different types and in various tively, a direct nspection of the reading
degrees of severity. The types are dysphonetic graph tself, which s another men option,
(auditory), dyseidetic (visual), or the combination will revea I this pattern.
groupdysphoneidetic (auditory and visual). A
child having a learning problem can often be iden- If modrate or severe dyslexia s suspected n a
tified by a history (see Figure 16-13). Clinical expe- prepubescent child, we often recommend a com-
rience has ndicated that if a parent rates five or plete perceptual skills assessment, usually per-
more of these behaviors as occurring always or fre- formed by optometric specialists, and a complete
quently, then the child s highiy suspect of having a psychoeducational assessment by the school or a
learning problem. prvate educational psychologist. Certainly, per-
The Visagraph profile also can be revealing ceptual screenng tests should be performed for
regarding reading strategies. The following features any child having readng diffcultes. We typcally
of the reading profile suggest some form of dyslexia: use at least three tests routinely: the Beery Visual-
Chapter16 479

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

Reading Profile Visagraph


Grade/Goal Grade Left ~ ' > t 5 6 7 S 9 1011 121314 15161718
Right Nomns ~ J i
"
Fixations/1 00 words 1 89 162 139 -
Regressions/100 words Av. Span of 16 18 31 | ________ Ipt'|
N E
Recognition (words) 0. Av. Duration 59 0.62 0.72

: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

100 Runs Rntate

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

Comments on Health Care optometric practitioners (Brock and many others)


Rehabilitaron of visual dysfunctions fits comfortably extended visin training to the treatment of nonstra-
within the primary health care model of clinical bismic binocular anomalies. There has been an
practice. Rehabilitation has been a partof traditional increasing emphasis on efficiency of visin n the last
health care from its inception; the concept of pre- severa! decades. There s growing awareness that effi-
vention was emphasized later. Modern health care cient (.e., accurate, fast, sustained, and integrated)
management, however, promotes the concept of visual ski lis are related to good scholastic progress,
enhanced performance in school, work, and play. occupational production, and achievement in sports,
This evolution also applies to visin therapy. as well as to avocational endeavors.
The ultmate goal for any patient being treated for The model of visin care and clinical practice con-
binocular anomalies s the achievement of clear, sin- tines to change. More and more doctors of optome-
gle, comfortable, and efficient binocular visin. This try consider themselves to be primary eye care
simple statement represents an evolving model of providers, and most optometry schools embrace this
visin care that contines to change. Practitioners in perspective. "Primary eye care" is a metaphor signify-
the nineteenth century were concerned almost exclu- ing, in part, the taking of responsibility as a ful I mem-
sively with clarty of eyesight. They prescribed specta- ber of the health care team: Optometrists are taking
cle lenses to correct blurred visin. Clear and single responsibility for the diagnosis and management of
binocular visin became the issue with the advent of eye disease and injury within the limits of the law
orthoptics. Effective therapeutic regimens for strabis- and standards of practice. It is time to make explicit
mus were ntroduced by Javal, Worth, and Maddox. another concept in our approach to binocular visin
Astute clinicians n the first half of the twentieth cen- therapy that has always been implicit: We are provid-
tury became aware of the relation between accom- ing oculomotor and binocular visin health manage-
modation and convergence. Knowledge of the zone ment. Optometrists are dedicated to meeting the
of clear single, comfortable binocular visin was visin and health care needs of their patients. Within
gained through various models of visin, such as this context, they help their patients to achieve clear,
graphical analysis and fixation disparity. As a result, single, comfortable, and efficient binocular visin.
484 Chapter16

REFERENCES 24. Griffin JR, Bui K, Ko C. Durability of Vision Therapy.


Research thesis. On file in the M.B. Ketchum Library, South
1. Grisham D, Simons H. Perspectives on Reading Disabili- ern California College of Optometry, Fullerton, Calif., 1991.
ties. In: Pediatric Optometry. Rosenbloom AA, Morgan 25. Wittenberg S. Brock's research in Stereopsis. AmJ Optom.
MW, eds. Philadelphia: Lippincott; 1990:518-559. 1981;58:663-666.
2. Sheedy JE, Parsons SD, The video display terminal eye 26. Camuccio D, Griffin JR. Visual skills therapy: a case
clinic: clinical report. Optom Vis Sc. 1990;67:622-626. report. Optom Monthly. 1982;73:94-96.
3. Mets M, Pnce RL. Contad lenses in the management of 27. Grisham JD. A short program for accommodative insuffi
myopic anisometropic amblyopia. Am J Ophthalmol. 1981; ciency. Rev Optom. 1978;115:35.
91:484^t89. 28. Vision, learning and dyslexia: a joint organizaron policy
4. Bannon RE. Clinical Manual on Aniseikonia. Buffalo, N.Y.: statement of the American Academy of Optometry and
American Optical; 1976. the American Optometric Association. J Am Optom
5. Ogle KN. Research n Binocular Vision. Philadelphia: Assoc. 1997;68:284-286.
Saunders; 1950:264. 29. Learning disabilities, dyslexia, and visin: a subject
6. Polasky M. Aniseikonia Cookbook. Columbus, Ohio: The review, Pediatrics. 1998;102:1217-1219.
Ohio State University School of Optometry; 1974. 30. Grisham JD, Sheppard MM, Tran WU. Visual symptoms and
7. Ryan VI. Predicting aniseikonia in anisometropia. Am ] reading performance. Optom Vis Sci. 1993;70:384-391.
Optom. 1975;52:96-105. 31. Flax N. The contribution of visual problems to learning
8. Lubkin V, Shippman S, Bennett G, et al. Aniseikonia disabilityJAm Optom Assoc. 1970;41:841-845.
quantification: error rate of rule of thumb estimation. Bin- 32. Simons HD, Gassler PA. Vision anomalies and reading
ocul Vis Srabismus Q. 1999;14:191-196. skill: a meta-analysis of the literature. Am J Optom Phys-
9. Kleinstein RN. Iseikonic trial lenses: an aid to diagnosing iolOpt. 1988;65:893-904.
aniseikonia. Optom Monthly. 1978;69:132-137. 33. Haddad HM, Isaacs NS, Onghena K, Mazor A. The use of
10. Koetting RA. Stereopsis and presbyopes fitted with single orthoptics in dyslexia.,/ Learn Disabil. 1984;17:142-144.
visin contact lenses. Am J Optom Arch Am Acad Optom. 34. Griffin JR. Office testing for dyslexia. Curr Opin Ophthal
1970;47:557-561. mol. 1992;3:35-39.
11. Emmes AB. A statistical study of clinical scores obtained 35. Griffin JR. Optometry's role n reading dysfunction. ]
in the Wirt Stereopsis test. Am J Optom Arch Am Acad Optom Vis Dev. 1999;30:122-131.
Optom. 1961;38:298-400. 36. Griffin JR, Christenson GN, Wesson MD, Erickson GB.
12. Sheedy JE, Harris MG, Busby L, et al. Monovision contact Optometric Management of Reading Dysfunction. Bos
lens wear and occupational task performance. Am J ton: Butterworth-Heinemann; 1997.
Optom Physiol Opt. 1988;65:14-18. 37. Lee S, Grisham JD. Establishing History tems for Learning
13. Josephson JE, Erickson P, BackA, etal. Monovision. J Am Disabled Children. Doctoral thesis. On file n the Univer
Optom Assoc. 1990;61:820-826. sity of California, Berkeley, Library, 1975.
14. Schor C, Carson M, Peterson G, et al. Effects of interocu 38. Colby D, Laukkanen HR, Yolton RL. Use of theTaylorVis-
lar blur suppression ability on monovision tasks perfor agraph II system to evalate eye movements made during
mance. ] Am Optom Assoc. 1989;60:188-192. reading. 7 Am Optom Assoc. 1998;69:22-32.
15. Josephson JE, Caffery BE. Monovision vs. bifocal contact 39. Stark L, Giveen S, Terdiman J. Specific Dyslexia and Eye
lenses. A crossover study. J Am Optom Assoc. 1987;58: Movements. In: Vision and Visual Dyslexia. Stein J, ed.
652-654. Boca Ratn, Fia.: CRC Press; 1991:203-232.
16. Lebow KA, Goldberg JB. Characteristics of binocular 40. Sheedy JE, Bailey IL, Muri M, Bass E. Binocular vs. monoc
visin found for presbyopic patients wearing single visin ular task performance. Am J Optom Physiol Opt. 1986;63
contact lenses. J Am Optom Assoc. 1975;46:1116-1123. (10):839-846.
17. Bahill AT, Adler D, Stark L. Most naturally occurring human 41. Trachtman JN. The relationship between ocular motilities
saccades have magnitudes of 15 degrees or less. Invest and batting averages n little leaguers. Am J Optom Arch
Ophthalmol. 1975;14:468^69. Am Acad Optom. 1973;50:914-919.
18. Griffin J. Pursuit fixations: an overview of training proce- 42. Christenson GN, Winkelstein AM. Visual skills of athletes
dures. Optom Weekly. 1976;67:534-537. versus non-athletes: development of sports visin batterv,
19. Keller JT, Amos JE. Low plus lenses and visual performance: ;Am Optom Assoc. 1988;59:666-675.
acritical review. J Am Optom Assoc. 1979;50:1005-1011. 43. Melcher MH, Lund DR. Sports visin and the high school
20. Greenspan SB. Behavioral effects of children's nearpoint student athlete. J Am Optom Assoc. 1992;63:466-474.
lenses. J Am Optom Assoc. 1975;46:1031-1036. 44. Ridini LM. Relationship between psychological fundios
21. Pierce JR. A response to low plus lenses and visual perfor tests and selected sports skills of boys in jnior high
mance: a critical review. J Am Optom Assoc. 1980;51:453- school. Res OAm Health Phys Ed. 1968;39:674-683.
459. 45. Solomon H, Zinn WJ, Vacroux A. Dynamic stereoacuity. a
22. Grisham JD, Bowman MC, Owyang LA, Chan CL. Ver- test for hitting a baseball? J Am Optom Assoc. 1988;59:522-
gence orthoptics: validity and persistence of the training 526.
effect. Optom Vis Sci. 1991;68:441-451. 46. Stein CD, Arterburn MR, Stern NS. Vision and sports: s
23. Patano F. Orthoptic treatment of convergence insufficiency: review of the literature. J Am Optom Assoc. 1982:53:
a two year follow-up report. Am OrthoptJ. 1982;32:73-80. 627-633.
PART THREE

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

Mirror Stereoscope (T13,2, T14.4) 490 (T14.13, Pencil Push-Ups and


Purpose 490 Equipment 490 Push-Aways) 497 Purposes 497
Recommended Office Vision Training Equipment 497 Recommended Office
Instructions 490 Vision Training
Home Vision Training Instructions 491 Instructions 497
Dual Polachrome Illuminated Trainer Home Vision Training Instructions 498
Vectograms and Tranaglyphs for Divergence Brock String and Beads with Base-1 n Prism
Training at Near (TI 3.8) 491 Purposes (T13.6) 498 ?f
491 Equipment 491 Recommended Office Purposes 498 Equipment 498
Vision Training Recommended Office Vision Training
Instructions 491 Instructions 498
Home Vision Training Instructions 492 Home Vision Training Instructions 499
Aperture-Rule Trainer, Double Aperture Brewster Stereoscope (T13.3, T13.4) 499
(T13.13) 492 Purposes 492 Purposes 499 Equipment 499
Equipment 493 Recommended Recommended Office Vision Training
Office Vision Training Instructions 499
Instructions 493 Home Vision Training Instructions 500
Home Vision Training Instructions 494 PeripheraJ Fusin Rings (T13.7) 500
Orthopic fusin (T13.15) 494 Purposes Purposes 500 Equipment 500
494 Equipment 494 Recommended Office Recommended Office Vision Training
Vision Training Instructions 500
Instruction 494 Home Vision Training Instructions 501
Home Vision Training Instructions 496 Televisin Trainers and Base-1 n Prisms
Remy Separator (T13.14) 496 Purposes (TI 2.8) 502 Purposes 502
496 Equipment 496 Recommended Office Equipment 502 Recommended Office
Vision Training Vision Training
Instructions 496 Instructions 502 Home Vision
Home Vision Training Instructions 497 Training Instructions 503
Pencil Push-Aways with Base-1n Prism
490 ChapteM?

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

FIGURE 17-1Front view of the


Bernell Mirror Stereoscope showing
how to measure relative vergence
demand using the ruler that comes
with the kit. Base-in is measured as
"Place end of rule with arrow on inner junction the W is widened; base-out s mea-
and O (ortho demand) on other inner junction." sured as the W is narrowed.
Chapter17 491

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

Ring seen by left eye 8. "Slide the vectos apart symmetrically by


Ring seen by right eye using both hands."
9. "Continu moving the targets apart until
there is blurring or doubling."
10. "After doubling, move the targets closer
together to fuse them."
11. "Record the amount of divergence for blur
ring, doubling, and recovering to fusin."
12. "Repeat the foregoing steps, as higher tar
get separations can be tolerated without
Letter D seen in opening of blur or doubling."
mask indicating 4 prism
diopters of base-in demand
Home Vision Training
FIGURE 17-2View of the Quoits vectographic target, iliustrating a instructions
base-in demand when letters are seen in the opening of the mask.
1. The goal of this technique is for you to
learn to turn your eyes efficiently as a team.
2. Put on the special glasses for this training
tion of muscular action). Slowly increase the Bl
technique as you did during training at the
demand by sliding the transparencies apart so that
office.
letters can be seen n the bottom (Figure 17-2,
3. Pay attention to the target, especially the
showing Bl demand). Ask your patient to report
suppression checks. Notice what happens
whether the target appears to float closer or away or
when you cover an eye. Look for any images
whether the target appears to ncrease or decrease
that disappear at any time during training.
in size. Explain small-in/large-out (SILO) to your
4. Try to keep the target single and clear.
patient. Record mximum blurpoint, breakpoint,
Begin to pul the vectos apart and maintain
and recovery point. If there was suppression, have
fusin until doubling occurs. Record the
the patient describe which eye experienced t and
letter seen through the mask. Also, notice
its frequency.
any changes n the target or whether the
Next, train step vergences by having the patient
target changes n any way.
fuse the target while shifting from a Bl demand to
5. If suppression occurs at any time, break
the ortho demand. Eventually, the patient should
suppression by blinking. If the doubling of
be able to shift from Bl to BO to Bl, and so on.
the target remains, make the picture into
Recommended oral instructions follow:
one by moving the targets closer together.
1. "Let's start with the Quoits vectos and look
It should be noted that if the Dual Polachrome
at them from a distance of, say, 16 n., or
Illuminated Trainer s usually not taken home,
40 cm, from the Dual Polachrome Illumi-
Minivectograms and Minitranaglyphs are suitable
natedTrainer."
for home visin training. The home training
2. "Please put on the crossed polarizing fil-
instructions with these tools are basically the same
ters and look at the illuminated Quoits
as those for office training with the Dual Polach-
(rope rings)."
rome Illuminated Trainer.
3. "SIde the vectos together so that a zero
(0) appears in the window of the mask."
4. "Cover the right eye and notice that the R
disappears and also the vertical line of the APERTURE-RULE TRAINER,
plus sign at the top of the target." DOUBLE APERTURE (T13.13)
5. "Uncover the eye and try to see the plus
sign and both the R and the L." Purposes
6. "Look atthe fused ring (Quoits) and notice The purpose of the Aperture-Rule Trainer s to
the depth perception, which s stereopsis." improve the range and speed of fusional diver-
7. "Slowly slide the vectos apart so that let gence (Bl training). The device can also monitor
ters show through the mask." suppression during fusional divergence demands.
Chapter17 493

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

Recommended Office Vision Here card


here

Training Instructions Tip of Nose Here


The technique used for correcting convergence
excess is similar to that used for correcting con- FIGURE 17-4Top view of the rule showing where the patient's nose
s placed on the proximal end, where the target cards are placed
vergence insufficiency, except that a double toward the middle, and where pointers can be inserted on the distal
aperture is used rather than a single aperture. A portion of the rule. The Aperture-Rule Trainer is for base-in demand
difference s seen also in the instructions given to training when the double aperture slide is used.
the patient. Remember that n cases of conver-
gence nsufficiency, the training is helped by
fusional divergence? Is the fused image clear? Are
having the patient look at a pointer tip placed
there any suppression clues missing? Are the sup-
inside the single aperture. Conversely, n cases of
pression clues exactly lined up, as in zero fixation
convergence excess, the patient is instructed to
disparity? Continu on through cards 2-7, if possi-
look farther away by looking above the aperture
ble. What is the highest card number on which
slides and target card. This is beyond the plae of
your patient can perform with clear, single binocu-
the double aperture slider and even beyond the
lar visin without suppression? What s the Bl
target.
demand on vergence? What is the highest-num-
The emphasis for convergence excess patients s
bered card with which your patient can succeed
on fusional divergence training. A pointer stick
without evidence of any fixation disparity while
may be i nserted into a hole at the far end of the
maintaining clear, single binocular visin? Calc-
rule for the patient to view (see Figure 17-4 illus-
late the vergence demand by multiplying 2.5 by
trating position B on the rule). This helps patients
the card number. For example, card 4 s 10A.
to diverge their eyes n relation to the target, which
Recommended oral nstructions follow:
is nearer to the patient. Set up the nstrument for
your patients and have them go through the first
two cards, which are for suppression (set at posi-
tion A) and alignment checks.
Proceed with card 1 (2.5 x 1 = 2.5A Bl demand).
Can your patient fuse the two targets by using
494 Chapter 17

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

gence. The patient should have the same "feeling"


when fusing the cards as when diverging in the
mirror stereoscope. If the patient cannot achieve
this at first, help by having your patient wear plus-
addition lenses. Estmate how much plus it will
take to achieve orthopic fusin. Give the least
amount of lens power (if any) needed by the
patient for 3 minutes of practice with clearness and
with stereopsis. Calclate the prism demand under
the conditions you have set for your patient. This is
accomplished by dividing the target separation (in
millimeters) by the viewing distance (in decime-
ters). For example, targets 60 mm apart at 4 dm
would have 15A Bl demand.
Recommended oral instructions follow:

1. "Hold the pair of eccentric circle cards at a


reading distance, ateye level. Lookthrough
not atthe cirels. Look at an object set on
a table beyond arm's length." (It helps to
have a blank wall as a background.) "Posi-
tion the two cards so the object s between
them." (Figure 17-5 Ilstrales a relatively
FIGURE 17-5Ratient learning the technique of orthopic fusin using
more distant target, eccentric circle cards, transparent eccentric circle targets. The patient uses a distant targeta
and images on the retina of each eye.) drinking cup, in this exampleto allow the eyes to be relatively
2. "If you can diverge your eyes (outward) and diverged in relation to the nearer circular targets.

keep them on the object, you will see three


cards." (See Figure 13-19.) If you see four
cards, move the cards nearer together or 6. "Note that the middle target is only a fused,
farther apart until the two inner cards composite image and appears to float n
superimpose and form a third fused image. space. Try moving the cards nearer and far
AIso, try placing the cards nearer or farther ther from you or holding the cards at a
away. Once you see three cards, hold the fixed distance from your face while you
cards steady at that distance." move closer to and farther from them."
3. "Slowly turn your head (without tilting) 7. "Now, repeat steps 3-6 with more widely
from side to side while you keep the fused separated targets."
middle card single. If t tends to double,
The following additional instruction may be
stop turning your head; look more intently
offered to patients who are unable to produce and
at the distant object, turning your eyes out
see three or four cards at any one time:
ward, to achieve a fused image again."
4. "Try to keep the stereopsis (depth percep- 8. "If you are unable to produce and see three or
tion) in the fused image. The smaller circle four cards at any time, you may not be able to
should be floating closer to you with this diverge your eyes and maintain that eye posture, or
setup." (Figure 1 7-5 shows displacement of you may be mentally suppressing an eye. In either
the smaller circles to image on the tempo case, do not practice with the transparent circles
ral reas of Panum in relation to the larger until you can perform the following exercise,
circles.) which is designed to let you learn how to use both
5. "Next, try to clear the image (e.g., letters eyes simultaneously."
C-L-E-A-R)." (See Figure 13-18.) "Concn a. "First, look at a small object across the room
trate on seeing the letters clearly. See the (e.g., a doorknob). If the distant object doubles,
letters while turning your head and keeping move closer to it or move t closer to you until t s
the middle target fused." seen as single. Extend your arm toward the object,
496 Chapter17

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

being fused, although the fused image may


be blurred."
4. "I will help you fuse the easiest pair of cir-
cles, those most narrowly separated, by
putting some plus lenses before your eyes
and even some BO prisms if necessary."
5. "When you can put the mages together to
see depth and al I the letters clearly, I will
reduce the optical power of the lenses and
prisms so you can work harder while main-
taining fusin of the circles."
6. "Your goal is to be able to fuse at least the
bottom pair of circles without any optical
aid. Hopefully, you can eventually fuse some
of the harder, more widely spaced pairs."

Home Vision Training


Instructions
The nstructions for home visin training are essen-
tially the same as those for office training. The
home visin training goal is to practice this tech-
nique for 30 minutes per day while maintaining
clear visin during fusin.

PENCIL PUSH-AWAYS WITH


BASE-IN PRISM (T14.13, PENCIL
PUSH-UPS AND PUSH-AWAYS)
Purposes
Pencil push-aways with Bl prism are designed to
ncrease fusional divergence ranges and to main-
tain bifixation with ncreasing Bl demand as view-
ing distance is ncreased.

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

green filters (see Figures 12-7 and 12-8). The Brock


string and beads is analogous to the three-dot card
without a septum, except that training is performed
at an intermedate distance rather than just at near.
The red-green filters n a spectacle frame are used to
break suppression.

Recommended Office Vision


Training Instructions
Have your patient become aware of exact bifixation
by having him or her look at various portions of the
string. Do this by having your patient secure one end
FIGURE 17-7Patient's perception of exact bifixation of a bead on
the Brock string. of the string to something that is near chin height
(e.g., a doorknob), or you can hold the distal end of
the string for your patient. Next, have your patient
hold the other end of the string on the tip of the nose.
2. "Now please hold this prism lens before The nearest bead on the string can be at your patient's
your left eye and try to maintain fusin." nearpoint of convergence, and the other two beads
3. "I am going to move the penlight target are placed farther away (e.g., 20 cm and 40 cm).
away while you try to keep the target single." Have your patient bifixate the middle bead. Instruct
4. "I will add more power to the prism lens, your patient to notice that the two images of the string
and your goal s to keep the target single all should appear to cross exactly on this bead. (Figure
the time while I walk across the room." 17-7 shows the patient's perception.) Place the red-
green filter spectacles on your patient and repeat the
Home Vision Training preceding technique. The strings appear to be colored
Instructions and render suppression of two strings of opposite col-
The foregoing technique for office visin training ors Iess likely. Have your patient try to look at the
can be applied to home visin training as well. nearest bead. Ask whether the patient can see that the
The patient s told to practice this technique sev- strings cross exactly at the position of the nearest
eral times daily. Initially, have the patient practice bead and that the other beads are seen with homony-
push-aways. Later, he or she can look at a fixed mous diplopia. Next, have your patient bifixate the
target (e.g., televisin) and merely walk away farthest bead. Ask whether he or she perceives that
from it while wearing the Bl prisms and maintain- the images of the string appear to cross exactly at the
ing bifixation. The goal is to fuse the target contin- position of the farthest bead and that the nearer beads
ually while walking across the room away from are seen with heteronymous (crossed) diplopia. Move
the target. the beads farther away and determine whether your
patient can fuse properly and change fixation quickly
from one bead to another. Remove the red-green fil-
ters and have the patient bifixate each bead without
BROCK STRING AND BEADS
any suppression of the string or beads.
WITH BASE-IN PRISM (T13.6)
Recommended oral nstructions follow:
Purposes
1. "Secure one end of the string to a doorknob
The Brock string and beads with Bl prism is ntended
and hold the other end against the tip of
to monitor bifixation at various distances, to check
your nose."
for suppression, to improve fusional vergence ranges,
2. "I will place the three beads at various dis
and to develop vergence facility.
tances from your nose, from very near to
your arm's length."
Equipment 3. "You should see two strings as you look at
The equipment for the Brock string with Bl prism s the far bead. Cover one eye and notice that
a long string with three colored beads, and red and one of the images of the strings disappears."
Chapter17 499

4. "Now open both eyes and look at the mid- 87 mm


dle bead. You should be able to see two
strings that meet at the middle bead and
form an X pattern. Put on the red-green
glasses to make this more noticeable, espe
cial ly if you tend to suppress one of the
string images."
5. "Next, look at the nearest bead and repeat
the previous techniques."
6. "Try to look from one bead to another and
keep the string images meeting at exactly
where you are looking. In other words, the
0 <D
string images should cross exactly at the
bead at which you are looking. Your goal is
to be able to do this quickly and easily and
as the beads are moved farther away, per-
FIGURE 17-8Stereogram for a Brewster
haps to halfway across the room." stereoscope n which the relative vergence demand s zero (ortho
7. "Eventually you should be able to perform demand).
the technique while wearing Bl prisms and
without the need to wear red-green filters."
stereoscopes that are suitable for home visin train-
ing. To help the patient with an eso deviation to
Home Vision Training fuse targets in the stereoscope, the homologous
Instructions points should be fairly cise together, which creates
The same rgimen for home training is performed a BO prismatic relief. The separation would be less
as in office training, except that the patient must than 87 mm when the stereogram is placed at the
rely on his or her own visual feedback (i. e., where farpoint position. The patient is eventually given Bl
the strings cross or whether one disappears) to demands at which the separation exceeds 87 mm;
monitor exact convergence of the eyes and check this allows for fusional divergence training.
for suppression. The goal is to perform these tech-

\N\-\a\ \Y\e e^es axe do\u% as \V\ey raow \XO\T\ or\e


bead target to another, particu\ar\y when the beads Visin Training \nstruct\ons
are at relatively far distances. Have your patient try to fuse targets on a stereogram
in which there is a BO demand; the homologous
point separation should be less than 87 mm. Check
BREWSTER STEREOSCOPE to see whether there is good sensory fusin without
(T13.3,T13.4) suppression. Next, place the stereogram number 4
of the Visual Skills Series (.e., DB-4K) in the nstru-
Purposes ment (Figure 17-8). This s the ortho demand target
The purposes of the Brewster stereoscope are to with the red (top), white, and blue (bottom) circles.
develop good sensory fusin at far (optical infin- Have your patient try to fuse without suppression.
ity), to mprove fusional divergence at far, and to Next, have your patient try to fuse targets on a ste-
develop vergence facility at far. reogram n which the separation of homologous
points is greater than 87 mm; the goal s to fuse
clearly without suppression. Calclate the Bl ver-
Equipment
gence demand. (Refer to discussion n Chapter 13
The Keystone Telebinocular (see Figures 13-3 and for explanation.) Next, have your patient train for
13-4) s a standard nstrument for visin therapy. vergence facility with a double-paired training ste-
However, many other Brewster stereoscopes are reogram by having him or her look at the top pair of
available, such as the Biopter and the Bernell-O- targets on the stereogram in which the homologous
Scope, and the many types of hand-held Brewster point separation is greater than the bottom pair of
500 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

FIGURE 17-9The floating effect as


perceived by a patient when using
peripheral rings, such as Root Rings.

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.

eyes when corresponding filters are worn. Bl prisms


may take various forms, such as Fresnel (Figure
1 7-10), lose, or flipper prisms (Figure 17-11).
your fingertip, and then look farther away to
the floating ring. See whether you can per-
ceive the floating effect quickly each time. Recommended Office Vision
This builds good fusin recovery skills. 8. Training Instructions
Your doctor may also have you look at Have your patient wear crossed polarizing filters
black and white ring targets through while viewing a televisin screen at 1 m with the
crossed polarizing glasses. Quoits vectos, televisin Kit of Bernell (Figure 1 7-12; see also Fig-
for example, can be used in this manner by ure 12-9). Ask your patient to cise his or her right
separating them slightly while you look at eye and ask whether the entire screen is visible or
a distant target. Depending on which way whether one part is missing. This simlales the
you seprate the vectos, the fused ring can appearance of right-eye suppression (Figure 17-13).
appear either closer or farther than the With both eyes open, your patient should be able
single target at which you are looking. to see the entire screen through the filters. Add pro-
gressively larger amounts of Bl prism while your
patient attempts to maintain fusin without sup-
TELEVISIN TRAINERS AND pression. Determine the largest prism demand for
BASE-IN PRISMS (T12.8) which your patient is able to fuse for 30 seconds.
Recommended oral instructions follow:
Purposes
1. "Wear crossed polarizing filters while view
The use of televisin trainers and Bl prisms is
ing a televisin screen at 1 m with the Bernell
designed to monitor suppression during motor
Televisin Kit. Cise your right eye and report
fusin training, to train fusiona! vergence at far,
whether part of the screen s missing." (See
and to train vergence facility at far.
Figure 17-13.)
2. "Slowly back away from the televisin and
Equipment report whether part of the screen disap-
The televisin trainer is a ciear actate sheet with pears at any time. At a distance of at least
rubber suction cups that allow t to be placed on the 10 ft (3 m), add progressively larger
screen of a televisin set. On the actate sheet are amounts of Bl prism while you attempt to
two large sections of either red-green (anaglyphic) maintain fusin without suppression."
or crossed polarizing filters that produce mutual 3. "Perform step vergences as you quickly
exclusin of the images seen by the right and left place a Bl prism in front of your eyes, then
remove the prisms. Repeat this cycle severa!
Chapter17 503

FIGURE 17-12Examples of televi-


sin trainers, left view being polar-
ized and right view being anaglyphic
(red-green). (Courtesy of Bernell
Corp.)

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

Voluntary Convergence (T14.1) 506 Home Vision Training Instructions 517


Pur poses 506 Equipment 506 Vectograms and Tranaglyphs: Projected
Recommended Office Vision Training Base-Out Sudes (T14.11) 518
Instructions 506 Purposes 518 Equipment 518
Home Vision Training Instructions 506 Recommended Office Vision Training
Pencil Push-Ups and Push-Aways (T14.13, Instructions 518
T11.13, T14.1) 507 Purposes 507 Home Vision Training Instructions 519
Equipment 507 Recommended Office Chiastopic FusinColored Circles
Vision Training (TI 4.14) 519 Purposes 519
Instructions 508 Equipment 519 Recommended Office
Home Vision Training Instructions 509 Vision Training
Brock String and Beads (T14.5, TI 3.6) 509 Instructions 520
Purposes 509 Equipment 509 Home Vision Training Instructions 521
Recommended Office Vision Training Chiastopic FusinEccentric Circles
Instructions 509 (TI 4.14) 521 Purposes 521
Home Vision Training Instructions 510 Equipment 521 Recommended Office
Three-Dot Card (TI 4.6) 511 Purposes Vision Training
511 Equipment 511 Recommended Office Instructions 521
Vision Training Home Vision Training Instructions 522
Instructions 511 Vergence RockTelevisin Trainer and
Home Vision Training Instructions 512 Prisms(T14.16) 522 Purposes 522
Aperture-Rule Trainer, Single Aperture Equipment 522 Recommended Office
(TI 4,12) 512 Purposes 512 Vision Training
Equipment 512 Recommended Instructions 522
Office Vision Training Home Vision Training Instructions 523
Instructions 513 Vergence RockBar Reader and Prisms
Home Vision Training Instructions 514 (T14.17) 523 Purposes 523
Vectograms and Tranaglyphs: Convergence Equipment 524 Recommended Office
Training at Near (T14.9) 514 Purposes Vision Training
514 Equipment 514 Recommended Office Instructions 524
Vision Training Home Vision Training Instructions 524
Instructions 514 Vergence RockFraming and Prisms
Home Vision Training Instructions 516 (T14.18) 525 Purposes 525
Vectograms and Tranaglyphs: Convergence Equipment 525 Recommended Office
Wak-Aways (T14.10) 517 Purposes Vision Training
517 Equipment 517 Instructions 525 Home Vision
Training Instructions 525
506 Chapter18

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

crossed and looking directly at a pencil.


Your helper can tell you how you are doing,
as your doctor did in the office.
3. Next have your helper observe your eyes
while you imagine seeing a bug flying
directly in front of you, just a few inches from
the bridge of your nose. You need the helper
to tell you how you are doing, because you Perceived by Patient
may think you are crossing your eyes when
you really are not. For example, you may
FIGURE 18-1Illustration of
have your right eye on the target, but the left voluntary convergence n which
eye might be drifting out and away from the the patient s bifixating a
target. Your helper can inform you of this and drinking cup at a far distance (a)
encourage you to concntrate and make both and voluntarily converging the
eyes (b) while being aware of
eyes work together to point exartly on the tar the diplopic image of the distant
getyour fingertip, for example. target. Note that the patient has
4. When you can easily achieve the crossing uncrossed, homonymous,
by using an imaginary target, try to cross diplopia in this overconverged
state n which the right image s
your eyes by using as a cue the pulling sen- seen by the right eye and the left
sation of your eye muscles to achieve the mage by the left eye.
crossing. That is, cross your eyes without
the help of a target, either real or imagined.
5. When you can cross your eyes voluntarily vergence and
after proceeding through the steps 1-4, try divergence can also be trained, depend'mg on the
to perceive the doubleness of things across patient's heterophoria at ar and near. As examples,
the room as you hold your eyes n the con fusional convergence is being trained with push-ups
in cases of convergence insuf-ficiency, but fusional
verged posture.
divergence s being trained with push-aways in cases
6. The doubleness will actually help you to
of divergence excess.
cross your eyes and confirm that they are
crossed and that one eye is not suppressing
its image. This visual feedback lets you know Equipment
that you are performing the voluntary con An ordinary pencil, pen, pointer, sticker on a stick,
vergence technique properly. Besides visual or fingertip can be used for push-up and push-
feedback, you have the puUing sensation away training. A letter on an alphabet pencil s an
(which is kinesthetic and proprioceptive especially good target because t is large enough to
feedback) to tell you what s happening. be seen easily and yet has sufficient detail to allow
And, of course, you can have auditory feed for detection of blur. (See Figure 2-1, depicting
back from your helper at home to tell you, alphabet pencils.) The patient holds the pencil;
by observing your eyes, whether or not you other equipment s unnecessary, unless lose
are performing the technique properly. prisms are desired later n the training of this tech-
7. You should practice this technique as often nique for increased demands on fusional vergence.
and for as long each day as your doctor An solated object n the background, such as a
prescribes. This may be, for example, 5 clock on the wall, is also useful as a physiologic
minutes four times daily. diplopia clue to monitor suppression.

PENCIL PUSH-UPS AND


PUSH-AWAYS

Purposes
The main purpose of pencil push-ups s to increase
gross (absolute) convergence. Fusional (relative) con-
508 Chapter18

boning. Speed is not an mportant goal with this


training technique; rather, the patient should subjec-
tively be aware of intermittent blurs or breaks during
the push-up or push-away. Observe, objectively, the
accuracy of your patient's performance on push-ups
and push-aways.
Have your patient perform a series of push-ups
and push-aways, at least 10 cycles, while attempt-
ing to improve the nearpoint of convergence on
the push-ups and the quickness of fusional recov-
ery on the push-aways. As a check for suppression,
the patient should maintain awareness of physio-
logic diplopia of an object at far (see Figure 18-1).
Give the patient oral feedback as to performance
and continu to encourage greater effort.
You should demnstrate to your patient the
manner n which this technique s carried out,
ncluding the appropriate speed of tromboning the
target. Recommended oral instructions follow:
1."l want you to hold this pencil straight
ahead of you as far out as you can reach."
FIGURE 18-2Pencil push-up training for an exo deviation. a. The
patient s bifixating the pencil tip as t approaches a near distance.
2. "Look at the top letter on the pencil and try
b. The patient loses bifixation as the target advances nearer, and the to keep it clear during this exercise."
left eye s shown drifting outwardly n this example. 3. "Now move the pencil slowly toward your
nose and tell me whether the letter becomes
blurry, even momentarily."
Recommended Office Vision
4. "Keep moving the pencil closer and tell me
Training Instructions whether you notice it appearing to double
Have your patient hold the target, such as an as it gets closer to you."
alphabet pencil, at arm's length n the primary 5. "Try to cross your eyes to make it appear
position of gaze with instructions to bifixate a letter single again."
while maintaining clear visin. The pencil should 6. "Once the image doubles and you can't
then be moved slowly toward the nose. The patient make it single again, slowly push away the
is instructed to report the blurpoint (first unclear- pencil to recover a single mage, as soon as
ness) and breakpoint (diplopia) of the target. The possible, and continu to track it smoothly
distance from the spectacle plae of your patient as you push it al I the way to arm's length."
in which he or she first noticed blurring of the tar- 7. "I want you to do this as many times as you
get is recorded. The distance of first-noticed diplo- can for 2 minutes, then rest your eyes. The
pia s similarly recorded. The patient should be goals are for you to fuse the target almost
aware of diplopia with cessation of bifixation, indi- all the way to your nose, to build stamina,
cating that there was no suppression of the image and to track the pencil smoothly during
of the target seen by that eye. The distance at both the push-ups and push-aways."
which there is loss of bifixation (objective view by
you, as n Figure 18-2) or at which your patient If desired, the patient can use a penlight as a fixa-
noticed diplopia (subjective view by the patient) is tion target to ncrease the sensitivity of objective
the nearpoint of convergence. The loss of bifixation assessment, as in Hirschberg testing.
s indicated in exo cases by an outward turning of If your patient reports suppression, either by not
an eye. (Note that in eso cases, an eye may be seen seeing a double mage when bifixation s lost at near
to turn inwardly as evidence of loss of bifixation.) or by losing perception of physiologic diplopia at far,
Have your patient move the target slowly away to t s mportant to break suppression before continuing
recover fusin and continu to track the target out to with this technique. Blinking the eyes, flashing a light
arm's length, thus working on the smoothness of shining on the target (e.g., pencil), movement of the
vergence tracking. This technique s known as trom- target, or the use of a penlight as a target (brightness
Chapter18 509

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

Bead image of right eye


Bead image of left eye

FIGURE 18-3Brock string percep-


tion n which there is an exo devia-
cin in relation to the intended bead
to be fixated. The intersection of the
string s seen behind the diplopic
bead images.

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

FIGURE 18-5A Minitranaglyph


shown n front of a standard-sized
Tranaglyph. (Courtesy of Bernell
Corp.)

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

evoked suppression, and how you were Left eye


able to break t." Quoits
Vectograms
6. "Record blur, break, recovery vales and
whether or not SILO was appreciated, and
describe any suppression that may have
occurred."
7. "When performing this technique at home,
remember to wear the special glasses and 12 convergence
hold the Minivectogram or Minitranaglyph demand

approximately 16 n. (40 cm) away from


you. Remember to keep the R card at zero
and move only the L card."
8. "Your goal for the week s to keep the target
single and clear without any of the letters
blinking off, up to the number agreed on
between you and your doctor. This goal is 6 convergence
demand
based on your demonstrated ability n the
office."

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

Life saver targets

s
fovea

Images seen by patient

Cyclopean eye

FIGURE 18-8Principie of chiastopic perception, illustrating cyclo-


pean projection. This diagram explains why the patient perceives
three images, the middle image being the fused composite and the lat-
eral images being seen homonymously.

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. Cross-fuse the cards with the eccentric cir-


cles to obtain three images, just as in the Recommended Office Vision
office method that you have learned, using Training Instructions
a pencil tip for assistance if necessary. Recommended oral instructions follow:
Chapter18 523

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

FIGURE 18-9Examples of bar


reading strips, either polarized or
anaglyphic, and larga vertical strips
used for large book pages. (Courtesv
of Bernell Corp.)

Equipment 3. "Read several sentences and try to keep


Reading bars are available n several forms. A sep- from suppressing either eye."
tum (e.g., a pend) or several of them can be 4. "You can try breaking a suppression by
placed vertically between the reading material and blinking an eye or by having t intermit-
the patient's eyes. A more convenient technique, tently and rapidly occluded."
however, s the use of either polarized or red-green 5. "When any suppression s overeme during
filter materials that are made n strips and placed reading, I want you to continu reading while
directly on the reading material (Figure 18-9). wearing this BO prism over your left eye."
6. "I want you to continu reading while also
wearing a BO prism over the right eye."
Recommended Office Vision
7. "I will remove the BO prism over each eye,
Training Instructions but I want you to do bar reading through
The patient wears the appropriate filters over any these flipper prisms that have powers of 8*
needed refractive correction (e.g., corrected ametro- Bl and 8A BO."
pia most plus [CAMP] lenses). The strips of filter 8. "When you can read without suppression
material are placed on the page of print to be read. while flipping the prisms approximately
The strips are interspaced on transparent plstic and every 3 seconds from Bl to BO, I will grad-
alternately clued to the eyes (refer to Figure 10-20). ually increase the power of the BO prisms
Recommended oral nstructions follow: in the flipper during this training tech
1. "Please read aloud this material that is nique."
suited for your grade level while wearing
the filters and looking at the print through
Home Vision Training
the vertically aligned strips."
2. "Suppression will be evident f you notice a
Instructions
filter strip appearing dark so that visibility 1. Wear the special filter spectacles and look
of the print beneath it is lost or greatly at print at your normal reading distance.
reduced." 2. Place the up-and-down strips on the page
Chapter 18 525

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

See Chapter 16 for further discussions of the tech- Purposes


niques listed n this chapter and for other tech- The ntent of use of the Wall Saccadic Fixator s
niques and therapies for dysfunctions of saccades, to improve saccadic speed using an eye-hand
pursuits, and accommodation. task. It also aids n eliminating head movement
during a saccadic task and in improving periph-
eral awareness.
ELECTRONIC FIXATION
INSTRUMENTS FOR Equipment
SACCADES (T16.12)
Equipment ncludes the Wayne Saccadic Fixator
The Wall Saccadic Fixator (and other similar instru- (see Figure 16-2), for example, and an eye patch (f
ments) are applied n this technique. training monocularly).
528 Chapter19

(Wayne) Saccadic Fixator. Refer to the manual of


9
other instruments (e.g., Acuvision 2000) for nstruc-
10 tions on settings for various training routines. These
large units are not practical for home visin training,
but some computerized programs are good for sac-
cadic training at home (e.g., HomeTherapy System
[HTS] computerized system). The patient purchases
an HTS disk that has a limited (but ampie) number
of repeats of each particular program dedicated to
various visual functions (e.g., accommodation, sac-
cades, and vergences).

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

motion s recommended, as that is the direction n


which most cursive writing is done (e.g., in writing
the vowels, a, e, /, o, and u) (Figure 19-2).
Recommended oral instructions follow:
1. "Be seated comfortably and hold the pend
comfortably." FIGURE 19-2lllustrat'ion of counterclockwise motion, which is
2. "Circle each number from 7, 2, 3, and so on." importan!, as in the continuous motion training technique.
3. "Make the circling n a counterclockwise
motion."
4. "Do not lift the pencil from the paper but keep your patient continu to underline until getting to the
circling until you see the next higher number letter b, and so on, al I the way to the letter z. Pencil
and draw a straight line to that number." movements should be continuous and steady without
5. "Record the time t took to complete the lifting the pencil from the page. Your patient should
exercise and check to see whether there are be encouraged to be as accurate as possible; if a let-
any errors." ter s skipped, he or she will be unable to complete
the entire alphabet. Once your patient is able to get
through the entire alphabet accurately, emphasize
Home Vision Training
timing to improve speed.
Instructions Observe your patient's performance for each eye
Instructions for home visin training are the same as as to accuracy, speed, head movement, and pos-
the instructions for office training. Countless varia- ture. Ann Arbor Tracking is mainly a home training
tions of worksheets for the technique of continuous technique; one set of recommended instructions
motion training can be devised by the doctor or here will suffice:
therapist. For young patients, a limited number can
be given (e.g., 1-10). For older children and adults, 1. "Please put this patch over your left eye."
the numbers could be many (e.g., 1-40). 2. "All 26 letters of the alphabet are hidden in
this 'paragraph.' Your job is to find each
hidden letter. Underline each letter and cir-
ANN ARBOR cle each hidden letter as you find it. Be
(MICHIGAN) TRACKING (T10.7) careful not to skip any or you w ill be
unable to get through the entire alphabet."
Purposes 3. "Remember to maintain a good working
Ann Arbor Tracking is used to improve fine sac- distance from the paper."
cadic accuracy and to train fine saccadic speed: 4. "Keep the pencil on the paper when circling
each letter and when making return sweeps."
Equipment 5. "Now I would like you to proceed as quickly
The Ann Arbor (Michigan) Tracking technique uses and accurately as you can. I am going to time
a page of this system's workbook (see a modified you. Your goal is to complete the paragraph n
sample n Figure 19-3a and performance of a less than 2 minutes. At home you can do two
patient in Figure 19-3b) and an eye patch for initial or three paragraphs per eye each day. Later,
monocular training. binocular training will be done."
An advanced level of Ann Arbor Tracking s
Recommended Office and Home Word Tracking (see Figure 19-3c).
Vision Training Instructions
Have your patient sit at a desk and put the Ann Arbor
Tracking worksheet in front of him or her. Be sure you SEQUENTIAL FIXATOR (T16.10)
remind your patient to practice good ergonomics.
Have your patient underline the letters starting at the Purposes
top left until getting to the letter a, which should be The sequential fixator is designed to improve accuracy
circled. Circling should be only one revolution, and speed of mdium or fine saccades. It can train
unlike that used in continuous motion (T16.6). Have accuracy and speed without the help of hand support.
530 Chapter19

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.

(at) more in him he see time could


is FIGURE 19-3Ann Arbor (Michigan) Tracking. a. Example of a
worksheet. b. Results of performance of a patient. Note that the
_ ^ m ak e t h en l i r s f f i a^J h at b e e n i t Q r o r r T )
accuracy is indicated by the letter z being the last circled letter. Also
jt e wh oCBf r om y ou f or ne w p eo pl e on Tat j m y note that the pencil lines indcate counterclockwise motions, and
Pbe m ad e ov er ea ?) di d o r down ar e onl y hi s the continuous line shows that the pencil never left the page. c. Por-
( fr orr T) at I , jyay ( be) fmd us e as was wat er tion of Word Tracking Workbook from Ann Arbor Publishers. This
technique trains saccadic tracking, scanning, and pencil skills. The
with loT le very afterOrom^ word he cali patient s to circle target words as quickly as possible without touch-
they may where ("be") most this (at) know ing any word or missing any target word. The time (minutes and sec-
no get onds), misses (Ms), and touches (7s) are recorded. More than 2
touches or misses means that the patient is working too quickly and
is-
should slow down to be more accurate. Three or four such work-
sheets are assigned each day for home training.
3, T =

Equipment the eye movements through the actate (or hole n a


An eye patch s used for nitial monocular training card sheet). Instruct your patient to move his or her
with the sequential fixator. The sequential fixator eyes to look at each target, going from left to right. A
includes a clear actate sheet with targets that may or return sweep from right to left s made to the next
may not be connected by horizontal lines. Note that line as each line s completed. Have your patient
this type of target can be used in both testing and maintain a rhythmic shift from target to target. Accu-
training of fine saccades. For training purposes, cus- rate rhythmic eye movements should be empha-
tom-made sheets can be created for office and home sized first.
training (see Figures 2-7 and 2-8 for examples). Once eye movements are accurate, speed of eye
movements should be addressed. A metronome s
useful to reglate desired speed demands. Observe
Recommended Office Vision your patient's performance for each eye as to accu-
Training Instructions racy of saccades, head movements, and rhythm.
Have your patient hold the sequential fixator in Recommended oral nstructions follow:
front at his or her reading distance. You should face
your patient so that you can observe the accuracy of 1. "Please place this eye patch over your left
Chapter19

532

FIGURE 19-4Example of a disk for


the standing rotator. (Courtesy of
Bernell Corp.)

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."

Home Vision Training


Instructions
A custom-made ball with string can be used at home,
and the nstructions are essentially the same as those
for office training. The cognitive challenge, as in
counting numbers, and vestibular loading challenge,
as in standing on one foot, may not be feasible at
home unless the helper s sufficiently experienced in
this training. The helper, however, could provide
some mild loading challenges by carrying on a con-
versation while pursuit training s performed with the
swinging ball.

FLASHLIGHT CHASE (T16.17)


Purposes
Accuracy, smoothness, and speed of pursuits are
mproved by the flashlight chase. The technique
also eliminates head movements during pursuit
eye movements.
Chapter19 533

Equipment white flashlights can be used. The patient, how-


Two flashlights with spot focus are needed to per- ever, can wear red-green filters to work on motor
form the flashlight chase, as is an eye patch for ini- fusin control while mproving pursuit skills.
tial monocular training. A red filter s needed for
one flashlight and a green filter for the other.
HART CHART NEAR-FAR ROCK
(T16.22)
Recommended Office Vision
Training Instructions Purposes
Have your patient wear the patch to train monocu- The Hart Chart near-far rock technique (created by
larly. When using two flashlights with white lights, Dr. Walter Hart, Tacoma, WA) s designed to help
have the patient hold one while you move the the patient to learn to shift focus of the eyes quickly
other flashlight randomly, putting the spot of light and accurately so as to build good accommodative
on walls or on the ceiling. The patient attempts to facility. The technique also will demnstrate to the
place his or her spot on yours and follow your patient the ocular sensation of response of accom-
rnoving spot. Training can be accomplished binoc- modation to stimuli and the response of relaxation
ularly when pursuit skills are adequate for each of accommodation.
eye. Red-green filters can be worn to put demands
on fusin while performing pursuits. Antisuppres-
Equipment
sion training can be achieved by placing a red fil-
ter on one flashlight and a green filter on the other. Equipment includes Hart Charts, one for near (10
This is similar to the Hess-Lancaster testing proce- rows of reduced letters) to approximate the equiva-
dure (see Figure 4-26). lent of 20/30 reduced Snellen and one for far (10
Recommended oral instructions follow: rows of larger letters) to approximate the equiva-
lent of 20/30 at 10 ft. (Figure 19-5 shows far and
1. "Place this eye patch over your left eye. near Hart Charts.) Also required is an eye patch for
Later, you will switch the patch to the other initial monocular training.
eye. Still later, you will remove the patch
and perform this training technique with
both eyes open." Recommended Office Vision
2. "Try to put your flashlight spot on mine and Training Instructions
move t to follow mine." Place the far chart on the wall at your patient's eye
3. "Put on the red and green glasses. Try to level at a distance of approximately 10 ft. Your patient
keep a single spot and follow t while look- should perform this activity through lenses correcting
ing with both eyes and tell me whether you any ametropia. Have your patient patch one eye and
see two spots, one red and the other green. stand as far away as possible (up to 10 ft) such that he
The red and green spots will be a combina- or she s still able to read the letters. The small chart
tion color when you have your spot exactly should be as cise to the eye as possible such that t is
on mine." still readable. (See Figure 10-13 showing patient with
4. "Now you hold the flashlight with the red two viewing distances.) These distances should be
spot and l'll hold the flashlight with the green maintained for training. Have your patient look at the
spot. Try to follow my green spot while keep- first letter on the large chart, calling t out when he or
ing your red spot exactly on mine." she can clear it. Then have your patient shift focus to
the first letter on the near chart, calling it out when he
or she can clear it. Continu until your patient com-
Home Vision Training pletes all unes, then switch to the other eye. Ask your
Instructions patient to notice what the eye feels like when he or
For the flashlight chase, home visin training uses she clears the far chart and what the eye feels like
the same technique as s employed at the office, when clearing the near chart. Be sure your patient
except that the parent (or home therapy helper) does not allow the near chart to move away from the
takes the place of the office therapist. Also, the red eye. Observe your patient's performance for each eye
and green flashlight torches may not be available as to which chart was easier to clear, which eye per-
for home training, in which case two ordinary formed better, and what training distances were used.
534 Chapter19

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

Dolch Basic Sight Words

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

Then record any subjective comments trie patient


made about this technique. Later, have the patient
perform this training technique with both eyes open.
Recommended oral instructions follow:

1. "Please place this patch over your left eye."


2. "Facing this chart on the wall, step back-
ward until you can barely see the letters
clearly. Now hold this little chart in your
hand and bring t as cise as you can to
your eye, so that you are still able to see it
clearly. Hold it there for this activity."
3. "Look at the far chart and tell me what the
first letter is when you can clear it. Then
look at the letter on the near chart and cali
t out as soon as you clear it. Then do the
next letter, and so on."
4. "Which chart is easier to clear? What does
your eye feel like when you look at the near
chart? At the far chart?"
5. "Remember to keep the near chart cise to
your eye."
6. "The purpose of this technique is for you to
feel the difference when you have to focus
cise and focus far."
7. "Complete the chart with one eye, then
switch to the other eye. Later, you will per
form the training with both eyes open. FIGURE 19-6Sample of various powers of flippers for accommoda-
8. "Your goal is to change focus at least 20 times tive rock. (Courtesy of Dr. Jonathan Spilkin, Optego Vision, Inc.,
Toronto, Ontario, Canad.)
per minute with one eye open and at least 12
times per minute with both eyes open."
9. "Your doctor will prescribe variations on this
training technique (e.g., looking at the first Equipment
letter on the far chart, the last letter on the Equipment required for the plus- and minus-lens
near chart, the second letter on the far chart, rock technique includes a set of plus-minus flip-
the next-to-last letter on the near chart, the pers (1.00 D, 1.50 D, 2.00 D, 2.50 D). (Figure
third letter on the far chart, and so on)." 19-6 shows a close-up view of sample plus-minus
flippers; see also Figure 2-17.) Also needed are an
eye patch, a polarized bar reader, polarized filters,
Home Vision Training a red-green bar reader, red-green filters, and aVec-
Instructions togram 9 target (see Figure 13-11 h).
Instructions for home visin training are essentially
the same as those for office training.
Recommended Office Vision
Training Instructions
PLUS- AND First train the patient monocularly: Your patient
MINUS-LENS ROCK (T16.23) should patch one eye and be wearing his or her
lenses, f there s ametropia. Seat your patient so
Purposes that a working distance of 40 cm is established
The plus- and minus-lens rock technique is intended between the eye and the target. Have your patient
to mprove accommodative facility, first monocu- hold the flipper and view a letter through one of the
larly, then binocularly. It also will help the patient to lenses. Once he or she s able to clear the letter,
develop speed and accuracy. have your patient flip to view through the opposite
538 Chapter19

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

Suggested Sequencing of Training Techniques Basic Exophoria and Divergence Excess


for Amblyopia 540 Exophoria 542
Suggested Sequencing of Training Techniques Convergence Insufficiency Exophoria 542
for Eso Deviations 540 Constant Basic Vision Training for Visual Skills Efficiency 543
Esotropa, Anomaious Retinal Saccadic Dysfunction 543 Pursuit
Correspondence, and Central Suppression Dysfunction 543 Accommodative
540 Dysfunction 543 Fusional Vergence
Convergence Excess Esotropa, Normal Dysfunction 543 Hyperphoria 543
Retinal Correspondence, and Suppression Stereopsis Deficiency 543 Practice
541 Intermittent Esotropa, Either Basic or Management in Vision Therapy 543 Prvate
Divergence Insufficiency 541 Basic Practice Dedicated to Vision
Esophoria 541 Suggested Sequencing of Therapy 544 Prvate General
Training Techniques for Exo Deviations Practice That Includes
541 Constant Basic Exotropia, Anomaious Vision Therapy 544 Prvate General
Retinal Correspondence, and Suppression Practico with a Part-Time
541 Vision Therapy Specialist 544
Divergence Excess Exotropia (Assuming Group Practice with a Vision Therapy
Some Sensory Fusin at Near) 542 Specialist 545
Convergence Insufficiency Exotropia Clinc of an Optometrc School 545
(Assuming Some Sensory Fusin at Far) Optometrists in an Ophthalmologic
542 Office 545
Comments 546

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

Suggested Sequencing of Training Techniques Basic Exophoria and Divergence Excess


for Amblyopia 540 Exophoria 542
Suggested Sequencing of Training Techniques Convergence Insufficiency Exophoria 542
for Eso Deviations 540 Constant Basic Vision Training for Visual Skills Efficiency 543
Esotropa, Anomalous Retina! Saccadic Dysfunction 543 Pursuit
Correspondence, and Central Suppression Dysfunction 543 Accommodative
540 Dysfunction 543 Fusiona! Vergence
Convergence Excess Esotropa, Normal Dysfunction 543 Hyperphoria 543
Retina! Correspondence, and Suppression Stereopsis Deficiency 543 Practice
541 Intermittent Esotropa, Either Basic or Management in Vision Therapy 543 Prvate
Divergence Insufficiency 541 Basic Practice Dedicated to Vision
Esophoria 541 Suggested Sequencing of Therapy 544 Prvate General
Training Techniques Practice That Includes
for Exo Deviations 541 Constant Vision Therapy 544 Prvate General
Basic Exotropia, Anomalous Retinal Practice with a Part-Time
Correspondence, and Suppression Vision Therapy Specialist 544
541 Group Practice with a Vision Therapy
Divergence Excess Exotropia (Assuming Specialist 545
Some Sensory Fusin at Near) 542 Clinic of an Optometric School 545
Convergence Insufficiency Exotropia Optometrists in an Ophthalmologic
(Assuming Some Sensory Fusin at Far) Office 545
542 Comments 546

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

SUGGESTED SEQUENCING OF SUGGESTED SEQUENCING OF


TRAINING TECHNIQUES FOR TRAINING TECHNIQUES FOR
AMBLYOPIA ESO DEVIATIONS

Develop central and steady fixation in cases of eccentric


Constant Basic Esotropa,
fixation Anomalous Retinal
T10.13 Basic central fixation training Correspondence, and
T10.14 Steadiness of fixation training Central Suppression
T10.15 Saccadic movements with foveal tag
T10.16 Foveal localization with fast pointing Establish normal retinal correspondence (NRC) and nor-
TO.17 Pursuits with foveal tag mal sensory fusin
TO.18 Resolution practice with foveal tag T11.1 Flashing targets at the objective angle
Improve ocular motility T11.2 Macular massage
Tracing and drawing Throwing T113 Vertical displacement of targets
and hitting games Video game T11.4 Altrnate fixation
tracking Swinging ball training T11.5 Entoptictags
Tracking with auditory feedback T11.8 Binocular luster training
Visual tracing Ann Arbor T11.9 Afterimages at the centration point
Tracking T13.1 Amblyoscopic divergence technique, if
moderately small angle
T10.1 T13.2 Bernell Mirror Stereoscope, base-in (Bl)
T10.2 training
T10.3 Establish physiologic diplopia if NRC
T10.4 T13.6 Brock string and beads, Bl training
T10.5 Increase fusiona! divergence
T10.6 T13.4 Brewster Stereoscope, tromboning
T10.7 T13.3 Brewster Stereoscope, isometric and step
Improve resolution vergences
T10.8 HartCharts T13.8 Vectograms and Tranaglyphs, divergence
T10.9 Counting small objects training at near
T10.10 Reading for resolution T13.9 Vectograms and Tranaglyphs, divergence
T10.11 Tachistoscopic training walk-aways
T10.12 Monocular telescope T13.10 Vectograms and Tranaglyphs, projected
Break suppression Bl sudes
T10.21 Red filter and red print T13.7 Peripheral fusin rings, Bl training at far
T10.22 Visual tracking with a Brewster stereo- T13.12 Vergence rock techniques (flipper prisms)
scope T13.13 Aperture-Rule Trainer (double aperture)
T10.23 Bar reading and tracking T13.14 Remy Separator
T13.15 Orthopic fusin
T13.16 Computerized divergence procedures
Chapter 20 541

Convergence Excess Esotropa, Basic Esophoria


Normal Retina! Correspondence,
Establish physiologic diplopia
and Suppression T13.6 Brock string and beads, Bl training
Increase fusional divergence at near
Establish sensory fusin if deviation is constant Vergence rock techniques (flipper prisms)
T12.1 Translid Binocular Interaction Trainer Aperture-Rule Trainer (double aperture)
T12.2 Major amblyoscope antisuppression therapy Vectograms and Tranaglyphs, divergence
T12.3 Penlight and filters training at near
T12.4 Hand-mirror superimposition Remy Separator
T12.5 Cheiroscopic games Orthopic fusin
Establish physiologic diplopia Computerized divergence procedures
T13.6 Brock string and beads, Bl training
Increase fusional divergence if deviation is ntermittent T13.12
T13.13
T13.4 Brewster stereoscope, tromboning
T13.3 Brewster stereoscope, isometric and step ver- T13.8
gences T13.9 Vectograms and Tranaglyphs,
T13.14
divergence walk-
T13.15
aways
T13.16
T13.10 Vectograms and Tranaglyphs, projected Bl sudes
Increase fusional divergence at far
T13.7 Peripheral fusin rings, Bl training at far T13.8
T13.4 Brewster stereoscope, tromboning
Vectograms and Tranaglyphs, divergence training
T13.3 Brewster stereoscope, isometric and step
at near
T13.12 Vergence rock techniques (flipper prisms) vergences
T13.13 Aperture-Rule Trainer (double aperture) T13.9 Vectograms and Tranaglyphs, divergence
T13.14 Remy Separator T13.15 Orthopic fusin walk-aways
T12.10 Reading bars T13.16 Computerized T13.10 Vectograms and Tranaglyphs, projected Bl
divergence procedures sudes
T13.7 Peripheral fusin rings, Bl training at far

Intermittent Esotropa, Either SUGGESTED SEQUENCING OF


Basic or Divergence Insufficiency TRAINING TECHNIQUES FOR
EXO DEVIATIONS
Establish physiologic diplopia
T13.6 Brock string and beads, Bl training Constant Basic Exotropia,
Increase fusional divergence at near Anomalous Retinal
T13.12 Vergence rock techniques (flipper prisms) Correspondence, and
T13.13 Aperture-Rule Trainer (double aperture)
T13.14 Remy Separator
Suppression
T13.15 Orthopic fusin Establish NRC and normal sensory fusin
T13.16 Computerized divergence procedures
Increase fusional divergence at far Gross convergence training
T13.4 Brewster stereoscope, tromboning Voluntary convergence
T13.3 Brewster stereoscope, isometric and step Flashing targets at the objective angle, f
vergences necessary
Amblyoscopic convergence technique
T13.9 Vectograms and Tranaglyphs, divergence
Peripheral fusin rings
walk-aways
T13.10 Vectograms and Tranaglyphs, projected Bl T11.13
sudes T14.1
T13.7 Peripheral fusin rings, Bl training at far T11.1

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

Divergence Excess Exotropia Basic Exophoria and


(Assuming Some Sensory Fusin at Divergence Excess Exophoria
Near) Increase fusional convergence at near
Increase fusional convergence at near T14.13 Pencil push-ups
T14.6 Three-dot card T14.6 Three-dot card
T14.4 Bernell Mirror Stereoscope T14.19 Pola-Mirror vergence techniques
Increase fusional convergence at far T14.4 Bernell Mirror Stereoscope
T14.5 Brock string and beads T14.9 Vectograms and Tranaglyphs, convergence
T14.7 Brewster stereoscope, sometric and step training at near
vergences T14.12 Aperture-Rule Trainer (single aperture)
T14.8 Brewster stereoscope, tromboning push- T14.14 Chiastopic fusin
aways T14.17 Bar reader with prisms
T14.10 Vectograms and Tranaglyphs, convergence T14.20 Computerized convergence training
walk-aways Increase fusional convergence at far
T14.11 Vectograms and Tranaglyphs, projected BO T14.5 Brock string and beads
sudes T14.7 Brewster stereoscope, isometric and step ver-
T14.16 Televisin trainer and prisms gences
T14.8 Brewster stereoscope, tromboning push-
aways
T14.10 Vectograms and Tranaglyphs, convergence
Convergence Insufficiency walk-aways
Exotropia (Assuming Some T14.11 Vectograms and Tranaglyphs, projected BO
sudes
Sensory Fusin at Far) T14.16 Televisin trainer and prisms
Increase fusional convergence at far
T14.5 Brock string and beads
T14.7 Brewster stereoscope, sometric and step
vergences
Convergence
T14.8 Brewster stereoscope, tromboning push- Insufficiency Exophoria
aways
T14.10 Vectograms and Tranaglyphs, convergence Increase fusional convergence at near
T14.13 Pencil push-ups
walk-aways
T14.5 Brock string and beads
T14.11 Vectograms and Tranaglyphs, projected BO
T14.6 Three-dot card
sudes
T14.19 Pola-Mirror vergence techniques
T14.16 Televisin trainer and prisms
T14.4 Bernell Mirror Stereoscope
Increase fusional convergence at near
T14.9 Vectograms and Tranaglyphs, convergence
T14.13 Pencil push-ups
training at near
T14.6 Three-dot card
T14.12 Aperture-Rule Trainer (single aperture)
T14.19 Pola-Mirror vergence techniques
T14.14 Chiastopic fusin
T14.4 Bernell Mirror Stereoscope
T14.17 Bar reader with prisms
T14.14 Chiastopic fusin
T14.20 Computerized convergence training
T14.9 Vectograms and Tranaglyphs, convergence
training at near
T14.12 Aperture-Rule Trainer (single aperture)
T14.17 Bar reader with prisms
Chapter 20 543

VISION TRAININGFOR Fusional Vergence Dysfunction


VISUAL SKILLS EFFICIENCY
Increase fusional divergence
Saccadic Dysfunction T13.12 Vergence rock techniques, flipper prisms
Aperture-Rule Trainer, double aperture
Improve eye-hand accuracy and speed Vectograms and Tranaglyphs, divergence
T16.1 Picking up objects training
T16.2 Toothpick in straw Orthopic fusin
T16.3 Peg-board games Computerized divergence training
T16.8 Dot-to-dot games
T16.9 Fillingos
T16.6 Continuous motion tasks
Improve saccadic accuracy and speed
T13.13
T16.4 Wall fixations
T13.8
T16.5 Fixations with an afterimage
T16.7 Lose prism steps
T16.10 Sequential fixation sheets T13.15
T16.11 Sequential fixation sheets with cognitive T13.16
Increase fusional convergence
demands
T14.13 Pencil push-ups
T16.12 Computerized programs
T14.6 Three-dot card
T14.9 Vectograms and Tranaglyphs, convergence
training at near
T14.12 Aperture-Rule Trainer (single aperture)
T14.14 Chiastopic fusin
T14.17 Bar reader with prisms
T14.20 Computerized convergence training
Intgrate accommodation and vergence
T14.5 Brock string and beads
T16.22 Jump focus rock T14.19
Pola-Mirror vergence techniques

Pursuit Dysfunction
Improve eye-hand accuracy and speed 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

Prvate Practice which a VT practice is in a distant city. In such set-


Dedicated to Vision Therapy tings, the optometrist treats only the anomalies with
the best prognosis for cure (e.g., convergence insuffi-
Fewer than 1 % of optometrists have practices dedi-
ciency with BO training, or convergence excess, with
cated solely toVT. Approximately half of these prac-
tices are operated by individual doctors, whereas relieving plus-addition lenses along with some Bl
the others generally involve one or two partners training techniques). Most of the visin training, how-
who also specialize n VT. The optometrist conducts ever, is prescribed for home visin training. Other-
the diagnostic workup and prescribes lenses, occlu- wise, referrals are made to other optometrists for
sion, and other passive forms of therapy, and thera- more complicated cases (e.g., strabismus and ambly-
opia) or to ophthalmologists for surgical consider-
pists do most of the visin training. Often, there are
ations in large-angle constant strabismus. The general
two therapists per doctor. Only about half of the
practitioner may treat amblyopia, particularly of the
patient visits are for treatment of binocular anoma-
lies, the other half being for vision-related learning anisometropic type, with lens corrections and patch-
ing. When there is strabismic amblyopia with eccen-
problems (e.g., reading dysfunction) and other spe-
cial therapies (e.g., sports visin). tric fixation, referral should be made.
The emphasis of treatment s on visin training.
Such practices, and those closely emulating them, Prvate General Practice
interchange the terms visin therapy and visin with a Part-Time Vision
training as if they are one and the same. Interven- Therapy Specialist
tion with extraocular muscle surgery tends to be
The typical scenario is for an expert in VT (e.g.,
minimized. Prisms and lenses, however, frequently
professor at an optometry school or a gradate res-
are prescribed for constant wear as part of the thera-
ident in VT) to see patients 1 or 2 days per week in
peutic rgimen. These practices appeal to people in
the office of a general practitioner of optometry.
the upper socioeconomic strata who can afford the
The optometrist provides most of the therapy, but
sometimes lengthy therapeutic programs (ranging
there is often a visin therapist to carry out the pre-
from months to more than a year). Third-party cov-
scribed rgimen of training. Most of the training,
erage (e.g., by insurance companies and even some
however, is home based.
school districts) may be accepted by these practices,
Both of the authors have been consultants for
which assists the less wealthy patients n receiving
optometrists in a prvate, usually solo, general prac-
care. Intense office visin training is conducted
tice. The proprietor of the office conducts primary
along with a modicum of home training, made pos-
eye and visin examinations, usually offers contact
sible by ampie equipment and materials given on
lens services, and possibly prescribes some low-
loan for that purpose. There is tight control of the
vision aids. The VT patient caseload s approxi-
patients by the doctor, the therapist, and the dedi-
mately 50% vision-related learning problems; 25%
cated patients (or parents, if patients are minors).
strabismus cases, more intermittent than constant
deviations; and 25% visual skills dysfunctions, such
Prvate General Practice That as poor vergences, saccades, and accommodative
Includes Vision Therapy dysfunctions (resulting in discomfort). Although the
Many optometric practitioners include VT to some practice generales some referrals to the VT special-
extent (from 1 % to 30% of office time). As happens ist, most of the referrals are from outside, by word of
in the dedicated specialty practice, passive therapy mouth, from optometrists, ophthalmologists, and
is prescribed in the form of lenses, prisms, and other professionals (e.g., teachers and educational
occlusion, and active therapy s mostly home specialists, school nurses, psychologists, and occu-
visin training, with a minor portion of the training pational therapists) who are aware of theVT special-
done in the office, often by the doctor. Relatively ist's expertise. Patients usually are affluent and can
few of these offices employ VT assistants. Treat- afford the traditional fee-for-service payments,
ment of binocular anomalies is the reason for most although third-party reimbursements are sought for
of the patient visits for VT. some of the patients. Remuneration to the VT spe-
The optometrist n general practice may wish to cialist is done in severa! ways, but the typical way s
include VT as a service to his or her patients. This s receiving a certain percentage of the gross revenue
particularly applicable in rural or remote locations in of theVT service.
Chapter 20 545

Group Practice with a Clinic of an Optometric School


Vision Therapy Specialist The doctor in a VT clinic of an optometric school
Large group practices might consist of three or acts as a supervisor to the students. Although the
more optometrists n a prvate practice or be part student may do much of the testing, the prescribed
of a health maintenance organizaron or other VT is determined by the instructing doctor. The
nstitutional setting such as a military clinic. One visin training s conducted primarily by the stu-
optometrist may specialize n contact lenses, dent, who serves n much the same manner as a VT
another in low-vision services, and another n VT. assistant n a prvate office. Approximately half of
Each practitioner might practice general optometry the VT patients are treated for binocular anomalies;
along with his or her particular specialty. Most of the others receive therapy for visual nformation
the VT patients have binocular anomalies, and rel- processing (e.g., visual memory and visual-motor
atively few are treated for vision-related learning ntegration) related to learning problems.
problems n such settings. Exceptions occur, how- Both authors have served as supervisors in a VT
ever, in small prvate group practices in which one clinic of an optometric school. The clinic at the
optometrist might undertake all aspects of VT. Southern California College of Optometry serves as
An example of a health maintenance organizaron an example. The prescribed regimens include the
(HMO) including a VT program s given. Ordinarily, full scope ofVT atthis institution. Patients are sched-
the optometrist sees 20 or so patients per day for uled once weekiy for a 45-minute appointment.
basic visin examinations. The group n which one of There are three arbitrary categories of appointments:
the authors conducted VT was composed of 10 strabismus-amblyopia (ST/A), visin efficiency (VE),
optometrists, and 1 day per week was set aside for VT and developmental visual information processing
by one optometrist. A similar amount of time was (DVIP).
devoted to other specialties, such as contact lenses As n the other VT settings described previously,
and low visin. Ratients were allowed a 45-minute home training is necessary. Because scheduling for
visit once weekly or more often f absolutely neces- optometry students allows for only once-weekly
sary. The majority of patients were strabismic chil- appointments, home visin training s greatly empha-
dren. The optometrist conducted the testing, made sized. In other settings, as in a prvate practice dedi-
diagnoses, and performed preoperative visin ther- cated to VT, the doctor has control of appointment
apy f surgery was anticipated. In some cases, surgery scheduling and, ideally, patents can be seen more
was not required if a functional cure was attained by than once per week when deemed necessary. Clinic
means of optical therapy and visin training. If sur- patients at an optometric school tend to be less afflu-
gery was performed, the optometrist would see the ent than those seen n prvate practces. Fortunately,
patient approximately 2 weeks after the operation. educational wavers sometimes allow for charging
Sometimes, only a cosmetic cure could be effected, reduced professional fees to patents.
but often a functional cure could be achieved when
all modes of VT (occlusion, lenses, prisms, training, Optometrists in an
and surgery) were provided. The average number of
Ophthalmologic Office
visits of training (pre- and postoperative) per patient
was approximately 8, but the range varied greatly Ophthalmologists specializing in pediatric and
depending on the case. Littie or no training was given strabismic care sometimes employ a certifed
when the prognosis was very poor. In such a practice, orthoptist to treat strabsmus and, possibly, hetero-
over time, the VT program becomes more acceptable phoria. Large ophthalmologc group practices
to the ophthalmologists and the administrators of the sometimes include one or more optometrists with
HMO. Besides the successes of therapy, a great deal various specialties (e.g., contact lenses, low visin,
of money can be saved for the group practice. and VT). The VT optometrist usually performs the
There are large group practices such as are found training alone, without an assistant. The patients
n military clinics and veterans' hospitals that care are mostly strabismic; few, if any, are seen for
for patients with noncomitant strabismus, often due vision-related learning problems. The emphasis
to disease or traumatic brain injury. The optometrist tends to be on pre- and postoperative VT (usually
treating such patients with lenses, prisms, and visin called orthoptics n these settings). Training, if any,
training can become a subspecialist in VT. is home-based. Nearly all the VT patients n this
setting have binocular anomalies, with most hav-
546 Chapter 20
549

Appendix A

Special Commentary: Vision, Learning, and DyslexiaA


Joint Organizational Policy Statement of the American
Academy of Optometry and the American Optometric
Association*

VISION AND LEARNING


Many children and adults continu to struggle with *Journal of the American Optometric Association 1997;68:284-
learning in the classroom and the workplace. 286.
Advances in information technology, its expanding
necessity, and ts accessibility are placing greater
demands on people for efficient learning and infor-
mation processing.
Learning is accomplished through complex and
interrelated processes, one of which is visin.
Determining the relationships between visin and
learning involves more than evaluating eye health
and visual acuity (clarity of sight). Problems in
identifying and treating people with learning-
related visin problems arise when such a limited
definition of visin is employed.
This policy statement addresses these issues,
which are important to individuis who have
learning-related visin problems, their families,
their teachers, the educational system, and society.

POLICY STATEMENT
People at risk for learning-related visin problems
should receive a comprehensive optometric 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.

1Always 2Frequently 3Occasionally 4Rarely 5Never 6Unknown

Hyperactive Poor ability to organize work


Easily distracted Indistinct speech
Short attention span Awkward or clumsy
Easily frustrated Poor peer group relationships
Impulsiva Behavior problems
Easily fatiqued 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

V. Physical Development: At what age n years and months did the child:

Speak words clearly? _________ Start to crawl? _________ Walk unaided?

Which phrase describes the child's physical maturity (circle number)?


1Physically mmature for age
2Average physical maturity for age
3Advanced physical maturity for age

VI. School Progress: Rate your child's progress n the following subjects:

1Below grade level 2Grade level 3Above grade level

Reading Spelling Writing Arithmetic


Art Physical Education Other?

With what specific type(s) of work is your child having trouble?

Have other family members had difficulties learning any of the above subjects?

No ____ Yes_____ If yes, state relationship to child and subjects: ___________

Does your child have memory difficulties? No ____ Yes ____ If so, what type of nformation?
Appendix B 553

Vil. General History

Is there a history of pregnancy or birth complication?


No ____ Yes_____ If yes, please explain: _________
Has there been any severe childhood illness, high fever, injury, or physical impairment?
No ____ Yes_____ If yes, please explain: _____________________________________
Has the child received a hearing test? No _
Yes Date
Has a hearing or speech deficiency been previously
diagnosed?
No ____ Yes_____ If yes, please explain: __________________
Date
Has the child received a complete eye examination? No ____ Yes .
Has a visual problem been diagnosed?
No ____ Yes_____ If yes, please explain: ____________________
Does the child have any allergies?
No ____ Yes_____ If yes, please explain: ____________________
Is the child taking any medications or pills? No _____ Yes_____
If yes, please list the medications, their purposes, and duration: ___

Has the child previously taken medication for attention dficit or hyperactivity? No _____ Yes .

VIII. Therapy

Has there been any previous therapy for learning difficulties or visual or speech problems?
No ____ Yes_____ If yes, please state the type of therapy, duration, and results: _________

If you would like a copy of our examination results sent to any individual or agency, please list
ame and address below:
1._______________________________________________
2._______________________________________________
3._______________________________________________
Date
Signature ________
Relationship to child
Comments:
Thank you.
554 Appendix C

Appendix C

Strabismus Examination Record


ame Examiner Date j

Address Recorder Birth i

City Phone Referred by Report Rec'd \


!

HISTORY

What is the main visin problem?

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?

Other pertinent history?

AMETROPIA AND GLASSES

a. Latest retinoscopy? b. Latest RE LE Date By

subjective c. Present glasses RE LE Date By

(major lens) d. Other (e.g., add) RE LE Date By

RE LE Date By

ACUITY

Rx a b c d (circle one) RE LE Method

Rx a b c d (circle one) RE LE Method

CONFRONTATION

Angle kappa and steadiness RE LE Suggests

Hirschberg, primary gaze. Rx RE LE Suggests


Hirschberg, cardinal fields:

Observations and remarks: epicanthus, facial asymmetries, ptosis, torticollis, etc.

NPC conv (cm): IPD:


Appendix C 555

OBJECTIVE COVER TEST

Rx at m

Unilateral cover RE, LE moves:

Cover LE, RE moves:

Altrnate RE fixating

LE fixating

(Unilateral neutralization):

(Lose prism test):


A
(AC/A = . . /1.00 D)

ADDITIONAL TEST RESULTS


Comitance Monocular fixation and amblyopia

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

Latera I ity Strabismus Laterality Strabismus


Comitance

ASSOCIATED CONDITIONS
Monocular fixation Amblyopia

Retinal correspondence Suppression

Fusin Ametropia

Other relevant conditions

IMPRESSIONS AND RECOMMENDATIONS

Impressions (ncluding frequency of strabismus, cosmesis, and prognosis)

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

When lateral displacement is known, stereoacuity


must be expressed first in terms of a theoretical
valu that represents the apparent linear displace-
ment. This is the x valu in the following formula
where fa = stereoacuity in seconds of are; IPD =
interpupillary distance; and d= the testing distance:

Eta = (206,000)

I.P.D. (x) d2

Assume, for instance, that the eyes are bifixating a


circle by means of polarizaron. Another target
(such as the disparate circles n the Wirt rings test)
is designed so that each element of the target can
be seen by only one eye. Assume that the lateral
displacement s 1 mm for this particular stereo-
scopic test, the IPD s 60 mm, and the testing dis-
tance is 40 cm (400 mm). Find xfrom the formula:

x x+d
dsplacement I.P.D.

x x + 400
T 60

59x = 400 x

= 6.78 mm

Now, substituting the valu for x into the linear for-


mula for stereoacuity:

60(6.78)
Eta = (206,000)
(400)2

Eta = 524 seconds of are


Appendixes E and F 557

Appendix E

Conversin of Prism Diopters and Degrees


Prism Diopters Degrees Degrees Prism Diopters

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

Visual Acuity and Visual Efficiency


Snellen Acuity Angle of Resolution Visual Efficiency (%) Percentage Loss of Vision

20/20 (6/6) 1.0' 100.0 0

20/25 (6/7.5) 1.25' 95.6 4.4

20/30 (6/9) 1.50' 91.4 8.6

20/40(6/12) 2' 83.6 16.4

20/50(6/15) 2.5' 76.5 23.5

20/60(6/18) 3' 69.9 30.1

20/70 (6/21) 3.5' 63.8 36.2

20/80 (6/24) 4' 58.5 41.5

20/100(6/30) 5' 48.9 51.1

20/200 (6/60) 10" 20.0 80.0

20/300 (6/90) 15' 8.2 91.8


558 Appendix G

Appendix G
Visual Skills Efficiency Evaluation (Testing Outline)
Visual Skills Efficiency Evaluation (Testing Outline) Date: _______________________________
Patient _____________________ Age ____ Reason for Examination _____________________

1.VISUALACUITY At Farpoint At Nearpoint


Lenses worn OD VA S C V OD SC V OD OS
OS OS C C V O D OS

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

Fixations 4+ steady for at least 10 secs


3+ steady for at least 5 secs
2+ hand support needed or <5 secs (fail)
1+ unsteady almost continuously (fail)
Pursuits 4+ smooth and accurate pursuits
3+ one fixation loss
2+ two fixation losses (fail)
1+ more than two fixation losses or any head movements (fail)
Saccades 4+ accurate
3+ accurate
2+ gross undershooting or overshooting or increased latency (fail)
1+ nability to perform task or greatly ncreased latency or any head movements (fail)
Developmental Eye Fail if below thirty-sixth percentile on any of the subtests
Movement (DEM) Test
King-Devick Test Eye-Trac Fail if 1 year or more below expected
or Visagraph Test Pass or fail (professional judgment required)

ACCOMMODATIVE SYSTEM

AMP= 15- 0.25 (age) Fail if 2.00 D or more below average


MAF Fail if <10 cycles per minute or if difference in eyes >2 cycles per minute (2.00 D)
BAF (with suppression Fail if <6 cycles per minute (2.00 D)
check)
NRA Fail if worse than +1.75 D
PRA Fail if worse than -1.75 D
Bin. x cyl. Fail if lag more than +0.75 D
MEM Fail if lag more than +0.75 D or any lead (-0.25 D or more)

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

Second-degree fusin (W4D/RL) Fail if lack of second-degree fusin (grades C and D)


Stereopsis Fail if contoured (nonrandom dot) stereoacuity of worse than 60 seconds of
are or random dot worse than 100 seconds of are
Suppression Pola-Mirror: at near, fail if one eye dark with mirror at 25 cm; at far (Vecto-
graphic Slide 20/30), fail if OD or OS letters suppressed

W4D/RL = Worth four-dot test/red lens test.


Note: Referral for visin therapy is not automatically made just because one or more of the criteria for failing may be
met; professional judgment is required.
Appendix I 561

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)

Double visin (two (0) (1) (2) (3) (4) (U)


images)
Eyestrain (discomfort) (0) (1) (2) (3) (4) (U)
Ti red eyes (0) (1) (2) (3) (4) (U)
Sensitivity to light (0) (1) (2) (3) (4) (U)
Eye redness (0) (D (2) (3) (4) (U)
Loses place reading (0) (1) (2) (3) (4) (U)

Skips letters, words, or (0) (D (2) (3) (4) (U)


lines
Covers one eye or tilts (0) (D (2) (3) (4) (U)
head
Distracted, restless, or (0) (D (2) (3) (4) (U)
inattentive
Avoids or dislikes (0) (D (2) (3) (4) (U)
reading

*Describe the location and severity of headaches.

How many hours of reading do you do each week on average? ____


How many hours do you use a computer each week or on average?
What is your chief concern or visin problem? _________________
Comments:_____________________________________________
562 Appendix J

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)

American Optometric Association Christenson Vision Care


243 Lindbergh Boulevard St. Louis, 2215 Vine Street, Su te C
MO63141 Tel: 800-262-2210 Hudson, Wl 54016 Tel:
Fax:314-991-4101 Vision education 715-381-1234 Fax: 715-
material 381-5357
Dyslexia screening, testing, and practice manage-
Ann Arbor Publications PO Box ment material
7249 Naples, FL 33940 Ann Arbor
(Michigan) Tracking Clement Clarke International
Ophthalmic Divisin Haag
Ann Arbor Publishers Limited Streit UK
PO Box 1 Clement Clarke International Limited
Belford, Northumberland, NE 70 7JX Edinburgh Way, Harlow Essex, CM 20
United Kingdom 2TT United Kingdom Tel: 44-0-1279-
Ann Arbor (Michigan) Tracking 414969 Fax:44-0-1279-456305
info@haag-streit-uk.com
Bernell Corporation http://www.haag-streit-uk.com
U.S. Optical Divisin, Vision Training Products, Inc. Synoptophore and SI des
4016 N. Home Street
Mishawaka, IN 46545 Creative Publications
Tel: 800-348-2225 5623 W. 115th Street
Fax:219-259-2102 Worth, IL 60453 Tel:
Accommodative Rock Cards (Terranova) 708-385-0110 Peg-
Aperture-Rule Trainer boards
Bernell Computer Software for Vision Skills, Com-
puterized Aided Vision Therapy (program by Dr. Designs for Vision 760
Gary Vogel) Koehler Avenue
Broken Wheel Test (visual acuity) Ronkonkoma, NY 11 779
Developmental Eye MovementTest (DEM) Tel: 800-345-4009
Dual Polachrome IlluminatedTrainer, Vectograms Yoke Prism Diagnostic Unit
and Tranaglyphs
Dyslexia screening and testing Efficient Seeing 7551 Soquel Drive
Flippertrial lens/prism holder Aptos, CA 95003 Tel: 408-688-2020
Flippers, prisms, and lenses Fax: 408-688-2036 Various visin
Hart Charts therapy material
Interferometer
Appendix J 563

Ferris State University, Michigan College of Optometry Keystone View


Attn: Dr. James Saladin Divisin of Mast/Keystone, Inc./Nevada Capital
1310CramerCircle Group, Inc.
Big Rapids, MI 49307 2200 Dickerson Road
Tel: 616-592-2194 Reno, NV 89503
Fax:616-592-3792 Tel: 800-806-6569
Saladin Near Point Balance Card Fax: 775-324-5375
Email: sales@keystoneview.com
Fresnel Prisms and Lens Co. Lifesaver Colored Circles (opaque and
Route 1, Box 298-3 Siren, Wl transparent)
54872 BrockTechnique (red-green peripheral
Fresnel Prisms and Lenses fusin rings)
Correct-Eye Scope and light boxes
Cemstone Educational Management, LLC Eccentric circles (opaque and transparent)
575 San Pablo Avenue, Suite D Rodeo, Sherman TVTrainer for Amblyopia and Strabismus
CA 94572 Tel: 510-245-7290 Fax:510- Stereograms (testing and training)
245-3418 Telebinocular and other Brewster stereoscopes
Dynamic Vision Training software program Van Orden Trainer
VT Playing Cards
Goffe Torgerson Vision Technology (GTVT)
2100 196th Street, SW, Suite 116 Lynwood, Lafayette Instrument 3700
WA98036 Tel: 800-848-8897 Fax: 206-776- Sagamore Parkway North PO
9455 Box 5729 Lafayette, IN 47093
Filtered Strips for bar reading and various visin Tel: 800-428-7545
therapy material Tachistoscopes

Cuiden Ophthalmics Lakeshore Curriculum Materials


PO Box 7154 2695 E. Domingues Street PO
ElkinsPark, PA 19027 Box 6261 Carson, CA 90749
Tel: 800-659-2250 Tel: 800-421-5354
Prisms Various developmental materials applicable to
visin therapy
Ideal School Supply 11000
S. Laurence Avenue Oak Light House Low Vision Services
Lawn, IL 60453 Tel: 312- New York Association for the Blind
425-0800 111 East 59th Street New York, NY
Walking Rail, Balance Disc, and various visin 10022
therapy material Light House Charts (Lea Symbols)

International Accuvision Systems Lombart Instrument 8676


7690 El Camino Real, Suite 202 Commerce Avenue San
Carlsbad, CA 92009 Tel: 619-753- Diego, CA92121 Tel: 800-
4477 Accuvision training 573-2020 Fax: 619-537-
578-8369
JW Engineering 8A Dike Vision therapy testing material
Orive Wesley Hills, NY
10952 Tel: 914-354-8025 Manico/Bloomington 418 East
Rotating Peg-Board 17th Street, Suite 2 PO Box
5504 Bloomington, IN 47408
564 Appendix J

Tel: 812-336-2567 Patch Works 7655 Scribner


Rotating Peg-BoardTrainer Drive Citrus Heights,
Translid Binocular InteractiveTrainer (TBI) CA95610 Tel: 916-726-
9649 Occlusion patches
Meto n e
2801 Thornton Avenue Parents Active for Vision Education (PAVE)
Burbank, CA91504 Tel: 9620 Chesapeake Drive, Suite 105 San Diego,
818-845-4874 Metronomes CA 92123 Tel: 619-467-9620 Fax:619-467-
9624
Midwest Vision Therapy Equipment Company, Inc. Information on visin therapy
PO Box 103 7
Cicero, IN 46034 Precisin Vision 944
Tel: 800-346-4925 First Street La Salle,
Fax:317-984-9661 IL61301 Lea Acuity
Accommodative Flippers Charts
Anti-Suppression Bar Reader
Home Therapy System (HTS) (program by Dr. Print Express (formerly Allbee Printing Co.)
Jeffrey Cooper and Rodney Bortel) 303 Jefferson Street Waterloo, IA 50701
Near-Far Accommodation Charts Root Rings
Polarized Glasses Three-dot card
Variable and NonvariableVectograms
RC Instruments
Optometric Extensin Program Foundation, PO Box 109
Inc. (OEP) 1558 East Port Court
1921 E. Carnegie Avenue, Suite 3-L Cicero, IN 46034
Santa Ana, CA 92705 Tel: 31 7-984-9400 or 888-810-3937
Tel: 714-250-8070 Fax:317-984-9661
Fax: 714-250-8157 Computer Orthoptics, Home Therapy
Accommodative rock charts System (HTS)
Ann Arbor (Michigan) Tracking (symbols, letters,
words, sentences) Richmond Products, Inc.
Dyslexia screening and testing 1021 S. Rogers Circle, #6
Hendrickson Lifesaver Cards Boca Ratn, FL 33487
Maples OculomotorTest AniseikoniaTest Book (Awaya test)
Psychometric Acuity Cards (Wesson) Bagolini striated lenses
Rotation Peg-Board Machine Bangerter Occlusion Foils
Super Stereoacuity Timed Tester Frisby Stereotests
Test of Auditory Analysis Ski lis (TAAS) Lang Stereotests I and II
TheTalking Pen Press-on prisms (Fresnel)
Various visin therapy testing, training, and infor- Prisms
mation material
Visual-Motor Integration (VMI)Test School of Optometry
Wayne Afterimage Strobe Flasher University of California
Wayne Computerized Saccadic Fixator Berkeley, CA 94720
Wesson Fixation Disparity Card Bailey-Hall Cereal Test, c/o Center for the Study
ofVisual Impairment Baily-Lovie Chart, c/o
Optego Vision Inc. c/o Dr. Center for the Study of
Jonathan Spilkin 700 Visual Impairment Tumbling f's, c/o
University Avenue Toronto, Optometry Alumni Association
Canad M5G1Z5
Flipper lenses for accommodative rock
Appendix J 565

Southern California College of Optometry New York, NY 11746


Campus Store Tel: 800-732-3758
2575 Yorba Linda Boulevard Fax:516-549-3156
Fullerton, CA 92831 Visagraph, Eye-Movement Recording System
Tel: 714-449-7434
Fax: 714-992-7810 Titmus Optical P.O.
Three-dot cards Box 191
Eccentric circles Petersburg,VA 23804
Alphabet pencils Tel: 800-446-1802
Various visin therapy testing and training Vision screening nstruments and material
material
Books on visin therapy Wayne Engineering
8242 North Christiana Avenue
Southern College of Optometry Bookstore Skokie, IL 60076
1245 Madison Avenue Memphis,TN 38104 Tel: 847-674-7166
Tel: 901-722-3291 Filters and flippers Fax:847-674-7196
Afterimage Strobe Flasher (Wayne After Image
Stereo Optical Company, Inc. Flash)
3539 North Kenton Avenue Perceptuomotor Pen (Talking Pen)
Chicago, IL 60641 Saccadic Fixator
Tel: 800-344-9500 Stand i ng Rotator (Wayne Robot Rotator, with
Fax:312-777-4985 auditory feedback)
Randot Preschool Stereoacuity Test Super Stereoacuity Timed Tester
Stereograms for Brewster stereoscopes
Various stereopsis tests, Vectograms Note that the preceding list s extensive but not
exhaustive n that many tems may have been
Taylor Associates 200- omitted for the sake of brevity. Also, many tech-
2 E. 2nd Street niques can be custom-made for particular patients'
Huntington Station needs. Furthermore, addresses and telephone and
fax numbers are subjectto change; these are up-to-
date only at the time of publication of this edition.

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

2.4. Position maintenance (fixation) testing with b. 10, lower, vergences


the 4+ system s done with the fixation target at c. 6, lower, saccades
_________ cm, and passing would result if steadi- d. 10, higher, saccades
ness is for at least__________ seconds; on a 5- e. 6, lower, vergences
point system, a rank of 4 would indcate steadiness
2.9. Nearpoint of convergence testing showing a
of at least _________ seconds.
breakpoint of 7 cm would indcate a ranking of
a. 40, 5, 5 _________ on a 5-point scale, whch s considered
b. 20, 5, 5 _________ , and calculatingthis distance, assuming
c. 40,5,10 an interpupillary distance of 60 mm (6 cm), would
d. 20, 10, 10 interestingly be converted to _________ prism
e. 40,10,10 diopters of absolute convergence.
2.5. Your patient is 10 years od and has an a. 2, adequate, 32
amplitude of accommodation of 10.5 D n the b. 3, weak, 42
right eye. This would indcate a rankng of c. 4, strong, 52
_________ on the 5-point system and would be d. 3, adequate, 62
consdered _________ . e. 2, weak, 72
a. 1, strong 2.10. Relative convergence is tested at the rate of
b. 2, weak _________ prism diopters per second to prevent
c. 3, adequate _________ , which is particularly more likely
d. 1, weak when base- ________ prism testing s done.
e. 2, strong
a. 4, prism adaptation, out
2.6. Monocular estmate method (MEM) retinos- b. 3, prism adaptation, in
copy is done at a viewing dstance of _________ , c. 1, suppression, out
and the patient initially wears his _________ d. 2, suppression, in
lenses; a lag of +0.75 is _________ . e. 3, blur, in
a. 40 cm, corrected ametropa most plus (CAMP) 2.11. Clinical testing of relative vergence should
for best visual acuty at far, passing begin with _________ testing and at __________ ,
b. habitual readng distance, habitual reading and a blurpoint is _________ .
lenses, failing a. convergence, near (40 cm), expected
c. 40 cm, CAMP, failing b. divergence, near (40 cm), not expected
d. habitual reading distance, CAMP, passing c. divergence, far (6 m), expected
e. habitual reading distance, habitual reading d. convergence, far (6 m), not expected
lenses, passing e. divergence, far (6 m), not expected
2.7. Excess of accommodation, as found with 2.12. Ranking of results of positive relative conver
MEM testing, would be indicated with a lens power gence testing at 40 cm as adequate would be a rank
of as small as _________ D. (on a 5-point scale) of _________ , with the blur
a. +0.50 point being _________ , breakpoint , and
b. +0.25 recovery to singleness. . prism diopters.
c. plano - a.
d. 0.25 - 1, 14, 18, 7
b. 2, 14, 18, 7
e. 0.50 c. 3, 14, 18,
2.8. Infacility of accommodation when tested d. 7
monocularly with +2.00-D flippers would be ade 3, 15, 19, 8
quate with _________ cycles per minute, and this e. 4 ,1 5 ,1 9 ,8
rate would normally be _________ when tested 2.13. Considering research reports and clinical
binocularly because of the effect of _________ . experience, recommended criteria n vergence
a. 6, higher, saccades facility testing at far (6 m) should be done with
________ and at near with__________ , and an
Self-Assessment Test 569

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

b. gradual, before 6 years, uncommon, normal, Chapter 9


common, anomalous 9.1. The father of orthoptics s considered to be
c. sudden, any age, common, abnormal, common, _________; the concept that strabismus s caused
normal by poor sensory fusin s largely attributed to
d. gradual, before 6 years, common, abnormal, _________ ; and _________ set the stage for the
common, anomalous conceptual framework and the measurement of the
e. sudden, any age, uncommon, abnormal, com zone of clear, single, comfortable binocular visin.
mon, normal
a. Sheard, Worth, Javal
8.2. Your patient has a paretic extraocular mus- b. Javal, Worth, Sheard
cle and compnsales by a head tilt toward the c. Worth, Javal, Sheard
right shoulder, the head turning to the right-hand d. Sheard, Javal, Worth
side, and chin depression. The isolated paretic e. Javal, Sheard, Worth
muscle s the
9.2. Beginning n the 1930s, it was _________
a. right superior oblique. who prometed a "holistic" concept of visin,
b. left superior oblique. which resulted n the concern for _________ and
c. right inferior oblique.
d. left inferior oblique.
a. Maddox, heterophoria, strabismus
e. right superior rectus.
b. Skeffington, heterophoria, strabismus
8.3. Your patient has an esotropa of the right c. Maddox, visin efficiency, visin enhancement
eye, and there is marked limitation of abduction d. Skeffington, visin efficiency, visin enhance
with widening of the eyelids on attempted abduc ment
tion. The nearpoint of convergence is remote. e. Maddox, heterophoria, visin efficiency
There is narrowing of the lids of the right eye on
9.3. After correcting for ametropia and providing
adduction. You suspect
other optical treatment, the general sequence of the
a. right lateral rectus paresis. first four visin training techniques n cases of strabis
b. dysthyroid eye disease. mus is for the purpose of eliminating
c. Duane retraction syndrome. ,
d. Brown syndrome. _________ , ________ , and ________ .
e. nternuclear ophthalmoplegia.
a. suppression, anomalous retinal correspon-
8.4. Your patient has normal binocular visin n dence (ARC), amblyopia, poor sensorimotor
the primary position of gaze but marked limitation fusin ranges
of elevation and widening of the palpebral fissure b. amblyopia, ARC, suppression, poor sensorimo
on adduction of the left eye. You suspect tor fusin ranges
c. ARC, amblyopia, poor sensorimotor fusin
a. fibrosis of the extraocular muscles. ranges, suppression
b. nternuclear ophthalmoplegia. d. suppression, amblyopia, poor sensorimotor
c. Parinaud syndrome. fusin ranges, ARC
d. Brown syndrome. e. amblyopia, suppression, ARC, poor sensorimo
e. chronic progressive external ophthalmoplegia. tor fusin ranges
8.5. Your patient is a man who has constant nys- 9.4. The use of split Vectograms for gradual base-
tagmus and reduced acuity of both eyes and in and base-out training exemplifies _________
dampens with convergence and with left gaze. This vergence training; phasic ntroduction of lose
is probably a case of _________ nystagmus. prisms, _________ vergence training; pencil push-
ups and push-aways, _________ vergence train
a. congenital
ing; and alternating fixation between two targets at
b. physiologic
two different distances n space, ver
c. voluntary
gence training.
d. latent
e. periodic alternating a. sliding, step, tromboning, jump
b. step, tromboning, jump, sliding
Self-Assessment Test 573

c. tromboning, jump, sliding, step techniques such as and


d. jump, sliding, step, tromboning
e. sliding, jump, tromboning, step a. peripheral fusin rings, anaglyphic fusin
9.5. Important in motivating patients, visin train- games, reading bars
ing techniques and instructions should be matched b. video game tracking, Ann Arbor (Michigan)
to the patient's cognitive level and understanding. Tracking, tachistoscopic training
An example would be _________ training for the c. video game tracking, reading bars, Ann Arbor
individual in the _________ stage of Piaget. (Michigan) Tracking
d. Ann Arbor (Michigan) Tracking, tachistoscopk
a. chiastopic fusin, preoperational
training, peripheral fusin rings
b. three-dot card, preoperational
c. chiastopic fusin, sensorimotor e. reading bars, video game tracking, tachisto
d. three-dot card, sensorimotor scopic training
e. Brewster stereoscope, sensorimotor The use of Haidinger brush training s an
techniques and is particu-
Chapter 10
10.1. In amblyopia therapy, any significant
_________ may be the most mportant factor in
the etiology and, in many cases of modrate or
marked _________ , correction with contact
lenses may be advised.
a. attitude problem, anisometropia
b. fusin problem, myopia
c. refractive error, anisometropia
d. attitude problem, myopia
e. fusin problem, astigmatism
10.2. Your patient s 25 years od and has ambly 10.5.
opia of the left eye of 20/200 (6/60). Patching ther example of
apy would most likely consist of larly good n cases of
a. ntermittent occlusion of the right eye. a. foveal tag, eccentric fixation
b. full-time altrnate occlusion. b. antisuppression, unsteady fixation
c. intermittent occlusion of the left eye. c. stereoacuity, eccentric fixation
d. full-time occlusion of the right eye. d. foveal tag, nystagmus
e. intermittent altrnate occlusion. e. antisuppression, unsteady fixation
10.3. Penalizaron becomes the preferred treat- 10.6. Your patient has 5A of steady, nasal, eccen
ment option n cases of amblyopia n which there tric fixation of the right eye. The patient views a
s and _ . black fixation spot on a Haidinger brush generator
at a 40-cm distance. The patient is expected to
a. latent nystagmus, intermittent unilateral stra-
report the brush perceived at a location
bismus
_________ mm to the__________ of the spot. Ple-
b. congenital nystagmus, constant unilateral stra-
optic training would be done by having the patient
bismus
fixate a small red spot located _________ mm to
c. latent nystagmus, constant alternating strabismus
the _________of the spot.
d. constant unilateral strabismus, allergy to the
bandage a. 10, left, 10, right
e. constant alternating strabismus, allergy to the b. 20, left, 20, right
bandage c. 10, right, 10, left
d. 20, right, 20, left
10.4. Examples of monocular fixation and motil- e. 40, left, O, center
ity activities for the amblyopic eye include training
10.7. Binocular training can usually be consid-
ered for ambiyopic patients when there is
_________ retinal correspondence, __________
visual acuity, and _________ suppression.
a. normal, fairly good, modrate or deep
b. anomalous, fairly good, shallow
c. normal, very poor, modrate or deep
d. anomalous, very poor, horror fusionis
e. anomalous, fairly good, horror fusionis
10.8. Your 28-year-old patient has constant
esotropa of 20A at far and the same at near and
has anomalous retinal correspondence, as found
on the Bagolini striated lens test. Cosmesis s fair
and the patient s considering having extraocular
574 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

gences would be trained by having the patient b. double, usually, 50


_________ and step vergence training would be c. single, not usually, 40
done by having the patient _________ and d. double, not usually, 40
emphasizing _________ demands. e. single, usually, 25
a. use prism flippers, look from bead to bead, 13.11. Your esophoric patient s using the Vod
base-in noy Aperture-Rule Trainer for base-in training and
b. look from bead to bead, use prism flippers, is viewing card 2. This creates a vergence demand
base-out of _________ prism diopters. A reasonable goal
c. use prism flippers, look from bead to bead, for the patient would be to master card number
base-out _________ , which creates a vergence demand of
d. look from bead to bead, use prism flippers, approximately _________ prism diopters.
base-in
a. 2 ,5 , 5
e. use prism flippers, look from bead to bead,
b. 5 ,5 ,1 0
neither base-in or base-out
c. 5, 7, 1 7
13.8. Your esophoric patient is using the Quoits d. 7, 7, 20
(No. 2) variable Vectogram while viewing at a 40- e. 10,10,20
cm distance. An instrument suitable for this target
is the _________ , and a letter D showing on the 13.12. Convergence excess esotropa patients
scale indicates a vergence demand of _________ having a high accommodative-convergence/accom-
prism diopter(s),_________ . modation ratio can usually be treated successfully
with visin training and an optical prescription of
a. Wheatstone stereoscope, 1, base-in _________. Amblyopia and anomalous retinal cor-
b. Brewster stereoscope, 1, base-in respondence are usually not present if there is
c. Dual Polachrome Illuminated Trainer, 4, base- fusin at _________ . This is a reason for a
out _________prognosis than in basic eso cases.
d. Brewster stereoscope, 4, base-in
e. Dual Polachrome Illuminated Trainer, 4, base- a. bifocals, far, better
in b. single visin plus lenses, near, better
c. bifocals, near, worse
13.9. Binocular accommodative rock is begun d. single visin plus lenses, far, worse
after _________ ski lis are adequate. Patients with e. bifocals, far, worse
_________ generally have difficulty clearing the
target when looking through the ________ 13.13. Your patient has basic esotropa. A typical
lenses. therapy sequence would be
a. vergence rock, convergence insufficiency, minus a. to treat any amblyopia or anomalous retinal cor-
b. monocular accommodative, convergence respondence (ARC), establsh sensory fusin at
excess, minus near, expand motor fusin ranges at near, and
c. vergence rock, convergence excess, plus work on motor fusin ranges at far.
d. monocular accommodative, convergence b. to establish sensory fusin at near, treat any
excess, plus amblyopia or ARC, expand motor fusin
e. monocular accommodative, divergence insuf ranges at near, and work on motor fusin
ficiency, minus ranges at far.
c. to treat any amblyopia or ARC, establish sen
13.10. For patients with either convergence
sory fusin at near, work on motor fusin at far,
excess or basic eso deviations, the Vodnoy Aper
and expand motor fusin ranges at near.
ture-Rule Trainer is used with the _________ aper-
d. expand motor fusin ranges at near, work on
ture and is _________ introduced at the beginning
motor fusin at far, establish sensory fusin at
of a visin therapy program; the targets at the O
near, and treat any amblyopia or ARC.
position remain at the fixation distance of
e. establish sensory fusin at near, expand motor
________ cm for this training technique.
fusin ranges at near, treat any amblyopia or
a. single, usually, 50 ARC, and work on motor fusin at far.
Self-Assessment Test 577

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

and s characterized as having a blurpoint of at Chapter 4


least 15A, breakpoint of at least 19A, and recovery
4.1.c/. Acute diseases (e.g., hemorrhage, viral
to singleness of at least 8A.
disease, or brain tumor) may cause the deviation
2.13.a. Refer to Table 2-24, which shows that
to be noncomitant. Because these conditions can
testing at far should have less base-in (4A) than
often be life-threatening, evaluation of comitancy
base-out (8A) demand and that a rank of 3 for ade-
s most mportant. Frequency of the manifest
quate is at least 5 cycles per minute (.e., 10 flips of
deviation is next in importance, because the
prism demands).
prognosis for functional cure is highly related to
2.14.C. Worth classified stereopsis as third-
the percentage of time the deviation is manifest.
degree fusin. The Randot Stereotest and the Lang
The prognosis of successful cure s better when
test are examples of noncontoured tests for global
the strabismus is less frequent and worse when it
stereopsis, as opposed to contoured tests, which
s more frequent.
are for local stereopsis. Crossed-polarizing filters
4.2.b. Refer to discussion on the three-step
are required for the Randot Stereotest but not for
method. Paresis of the right superior rectus muscle
the Lang test.
would cause the right eye to be hypotropic (i.e.,
relative hypertropia of the left eye). On right gaze,
Chapter 3 the hypotropia of the right eye would be worse, as
3.1.d. The calculated ratio would be 12/1 and the superior rectus becomes a pur elevator on
the gradient AC/A would most likely be lower abduction. A right head tilt would cause the other
owing to the effect of proximal convergence ntorting muscle of the right eye, which is the supe-
from far to near and possibly because of depth rior oblique, to come into play and further worsen
of focus with lens changes during the gradient the hypotropic deviation. Furthermore, the yoke
procedure. muscle of the right superior rectus is the left infe-
3.2.a. Relative vergence s measured from the rior oblique, and the head tilt would cause an
ortho demand (i.e., a point on the demand line) at overaction of the left inferior oblique muscle (an
a fixed distance. The blurpoint s traditionally des- elevator) due to Hering's law of equal innervation,
ignated by a circle, and convergence (base-out thus producing even greater hyper deviation of the
demand) is plotted to the right of the demand line left eye on right head tilt.
and divergence (base-in demand) to the left. 3.3.b. 4.3.e. Frequency of strabismus is either constant
An esophoric deviation would be relieved with (.e., 100% of the time) or intermittent (Le., 1-99%
base-out prism. According to the formula of of the time). Some authorities use the word occa-
Percival, the calculated valu would be 2A. Per- sional synonymously with intermittent. Laterality s
cival's criterion generally works well for esophoric designated as either unilateral (right or left) or as
patients, whereas Sheard's criterion generally works alternating.
well for exophoric patients. 4.4.a. A positive angle kappa (actually, angle
3.4.d. Refer to Figure 3-11b. In this case, the lambda) in esotropa gives the individual less of an
patient has an associated exophoria of 6A. The fixa- eso appearance, because an eye with a positive
tion disparity forced vergence curve determines angle kappa s anatomically positioned outward
the angle of fixation disparity by the magnitude (in (templeward) even though the eye may be cen-
minutes of are) of the Y ntercept; the associated trally fixating in the primary position of gaze. Like-
phoria s determined by the magnitude of the X wise, a narrow bridge of the nose gives a less eso
intercept (in prism diopters). Note that the associ- appearance than would a wide bridge.
ated phoria and the dissociated phoria are not cor-
related as to magnitude, but the direction (eso or Chapter 5
exo) of each often, but not always, is n agreement 5.1 .a. The Pola-Mirror test s vectographic and is
with that of the other. considered natural relative to the more laboratory-
3.5.c. A convenient mnemonic is that anoma- like tests employing septa or colored filters. Sup-
lies bearing the label excess have a high AC/A pression s not apt to be detected when testing
ratio, anomalies bearing the label basic have a conditions are unnatural, such as in a dark room
normal ratio, and those labeled insufficiency with a bright fixation light and with the patient
have a low ratio. looking through red and green filters.
582 Self-Assessment Test

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

fusional (disparity) eye movements. The patient in Chapter 13


this example would have gone from constant
13.1.C. The centration point is calculated by first
exotropia to intermittent exotropia, in which case
determining the dioptric distance, which is calcu-
ARC is intermittent. Vision therapy for intermittent
lated by dividing the farpoint deviation by the
exotropia would then commence and would carry
patient's interpupillary distance. In this case, the
a favorable prognosis for functional cure.
2.50 D represents a 40-cm distance (100/2.50). This
optical maneuver puts the patient's visual axes n
Chapter 12 the ortho posture, which allows for out-of-instru-
12.1.a. The suppression in this case is shallow, ment training with various techniques (e.g., Brock
and the treatment environment can be relatively string and beads, Pola-Mirror, and reading bars).
natural for this patient. The concept of graded 13.2.e. This patient has convergence excess esotro-
occlusion is consistent with the naturalness con- pa. Bilateral medial recession would reduce the
cept of testing the intensity of suppression; deeper magnitude of the eso deviation and possibly lower
suppressions require more unnatural occluding the accommodative-convergence/accommodation
techniques, as with dark red lenses or total occlu- (AC/A) ratio. It s ideal to lessen the near deviation to
sion with an opaque lens or patch. The dominant a greater extent than the far deviation n patients with
nonsuppressing eye is most often the one to be convergence excess. The other surgical options usu-
patched. ally either have no effect on the ratio or increase it;
12.2.b. Large, flashing, moving targets with high thus, those would not be recommended. 13.3.C. This
contrast help break suppression. These variables patient has divergence insufficiency in which the eso
are applicable to the suppressing eye. Other deviation is greater at far than at near. Push-away
important variables are attention, brightness, color, and walk-away training techniques allow for
tactile and kinesthetic senses, and the auditory relatively easy fusin of a penlight and anag-lyphic
sense. filters, to monitor diplopia or suppression at near;
12.3.e. Normally, the patient should see two increasing the viewing distance creates greater
images of the string crossing on a bifixated bead. demands on fusional divergence at far. Although
The image of a portion of string farther from the base-in training is the essence of treating patients
bead and viewed on the left s seen by the left eye; with eso deviations, this patient has eso at far, and
the string that should be viewed by the right eye is that problem must be addressed. It is true that the
not seen, indicating suppression of the right eye. Bernell Mirror Stereoscope with base-in training can
Seeing only one string or a portion of string miss- be effective, but this is training at near and therefore
ing indicates pathologic suppression. Having the does not provide the ultmate goal of good fusional
patient blink the right eye may act as an intermit- divergence at far, as with fusin walk-aways. Never-
tent stimulus (flashing) to break suppression. Using theless, optical infinity can be simulated with plus-
red and green filters makes the environment less addition lenses as with +3.00-D lenses using the
natural and also helps to break suppression. Room Bernell Mirror Stereoscope. The plus lenses can be
illumination should be ncreased, however, used to build a patient's confidence by increasing
because of the darkening effect of the filters. Only the base-in range on this instrument. 13.4.c.
one colored filter can be tried, but the comple- Widening the W creates base-in demands, an
mentary red and green colors applied to each eye outcome that s good for eso deviations at near, as
are less natural than application of a colored filter in convergence excess. The addition of plus
to only one eye. Closing the left eye forces percep- lenses can crate optical nfinity to simlate training
tion with the right eye; this can help the patient to at far; the power for this instrument would be +3.00
be aware of the right-eye suppression. 12.4.d. The D, which would be appropriate for eso at far, as in
Pola-Mirror monitors foveal suppression and is basic eso or divergence insufficiency. 13.5.e. The
used in testing such suppression when the mirror demand at far (0.00-D accommodat tive demand)
is held at a viewing distance of 25 cm (total would be 10A base-out, calculatediqpr
distance of 50 cm because of doubling of subtracting 67 from 87 to give a 20-mm
distance). A good clinical goal that is realistic and dis| ment inward of the homologous points
will ensure good bifoveal fusin with no suppres- and convergence (base-out) demand.
sion s a viewing distance of 75 cm. Dividing by 2 (2-dm viewing distance
[i.e., the decii
Self-Assessment Test
demand is calculated by mul-
A
10 . Similarly, 67 mm at near is a 4-
Catin than the

-
^ -
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

nsufficiency cases. In basic exo and divergence Chapter 16


excess cases, however, the mirror s pushed away so
16.1.b. Significantly different image sizes can
convergence can be worked on as the viewing dis-
often be tolerated for peripheral fusin, but 5% or
tance ncreases. Further convergence demands can
greater s too much for central fusin. Suppression
be made with base-out prisms. 14.9.a.
would be a means of relief, but this is not always
Converg enc e ns uf f ic ienc y c a n be quickly
possible and so the patient tries to adapt to the
treated in the elderly, and the success rate s more
superimposition of different-sized images that are
than 90%. Patients older than 75 years, however,
not fusible; severe symptoms result. 16.2.a. Gross
require more reinforcement visin ther-apy than
saccades are voluntary and relatively easy as
do younger patients.
compared with fine saccades, which are less under
volitional control. Therefore, training should
ChapteMS progress from easy to difficult; this is the general rule
15.1 .c. Duane retraction syndrome and Brown syn- in visin therapy. Similarly, start slow and work on
drome are examples of infantile noncomitant devia- faster saccadic demands (easy to difficult). When
tions. Anomalous retinal correspondence is an fairly good saccadic ability is shown with each eye
antidiplopia mechanism, and the patient with a life- monocularly, proceed to binocular training. Any
long condition of noncomitant strabismus needs all head movements should be under the control of the
the antidiplopia help possible. Breaking the anoma- patient; the patient should be made aware that the
lous retinal correspondence with visin therapy could finely tuned eye muscles are more efficient than the
cause the patient to have symptoms of diplopia or large neck muscles that move the head. Note that
might exacrbate any previously existing symptoms. fine saccades are important in reading; however,
15.2.e. Altrnate occlusion not only prevents large saccades may also need to be as efficient as
diplopia but also helps to prevent contractures. In possible in other endeavors such as for sports visin.
this case example, if only the right eye s occluded, Vision therapy for gross saccades might be necessary
contracture of the right medial rectus muscle is for certain patients.
likely. If only the left eye is occluded, contracture of 16.3.C/. Random dot stereograms usually have a
the left medial rectus muscle is likely. A permanent target that can be seen in four random positions: up,
esotropic condition is probable in either event. down, left, and right. With practice, perception of
15.3.C/. The base-out prism could provide fusin stereopsis is enhanced over time, and particularly so
by compensating for the eso deviation while mak- when the base-in and base-out vergence demands
ing the left eye turn inward and the right eye turn are met as the targets are separated to crate ver-
out, which would lessen the contracting of the gence demands. This is on the same basis as ordi-
right medial rectus muscle. There s some possibil- nary chiastopic and orthopic fusin techniques,
ity that the left medial rectus could develop con - except that the computer uses either colored filters
tracture, so the prism might be limited to part-time for mutual exclusin of each eye's target or liquid
use to maintain fusin more of the time than other- crystal flickering for this effect, Two chief advantages
wise without prism compensation. 15.4.d Yoked of computerized training are the random presenta-
prisms can be helpful in small to modrate tion of the targets and the fact that it is less labor-
amounts of head turn. The doctor should try various intensive than are hands-on fusin techniques (e.g.,
directions and powers of prisms to determine what eccentric circles for chiastopic and orthopic fusin).
actually works best. Theoretically, the patient likely 16.4.6. The kinetic cover test is similar to the
turns the head to his or her left when the eyes are static altrnate cover test but differs n that the
looking straight ahead, assuming a quiet zone on patient views a target moving closer (as in pencil
right gaze. Also theoretically, the patient n this push-ups) and farther away (as in pencil push-
example wants to look in right gaze to reduce the aways). The momentary deviations, either eso or
nystagmus. When looking straight ahead, turning the exo due to the changing of fixation distance, can
head to the left accomplishes this effect; the head be revealed on the kinetic cover test, whereas they
turn allows the patient to make a dextroversion and are not obvious on the static cover test. 16.5.e.
thus reduce the nystagmus. Base-left yoked prisms Refer to previous chapters that promote the goal
would make the eyes dextrovert, and the head could of clear, single, comfortable, efficient binocular
remain in the straight-ahead position. visin.
590 Glossary

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.

A A and V surgery in, 217 neutral-density filter testing in, 164-


patterns, 227-229, 228f visin training in, 217, 218-219 165
management of, 229 Abducens Accommodative fatigue, 76 occlusion, 283-284, 284t
nerve lesions, 239 Absolute Accommodative-convergence/accom- ophthalmoscopy in, 163-164
accommodation, 41-42, 42t, modation (AC/A) ratio, 70-72, 711 optokinetic nystagmus drum testing
49 gradient, 72, 132 in strabismus, 132 in, 156-158, 158f organic,
Absolute convergence, 49-52, 50f, 50t Adaptation test, for prism prescription, 144 photorefraction screening for,
developmental features of, 51-52 92 165-
facilityof, 51 functions of, 50-51 Adaptation theory, of anomalous reti- 166, 166f picture card testing
norms for, 50-51 stamina of, 51 nal correspondence, 174, 324 in, 153-154, 156f,
sufficiency of, 51 testing of, 49-50, 50f, Adherence syndromes, 247 Adjustable 157f
50t AC/A (accommodative- suture procedure, 203 Afterimage tag prevalence of, 143-144
convergence/ accommodation) ratio, techniques, 439-440 Afterimage psychogenic, 144 psychometric
70-72, 711, 132 Accommodation, 6, transfer training, 300-305 Afterimages chart testing in, 151-
7f, 40-49. See a/so at centration point, 337, 153, 151f, 152f-153f, 1 54f
Accommodation training 338f Afterimages testing, 37, pupillary constriction in, 148 pursuit
absolute, 41-42, 421, 49 in 176-179, 177f, movements n, 147-148 refraction
amblyopia, 148 amplitude of, 41- 178f, 179f testing in, 163 retinal function
42, 42t bioengineering model of, Allbee Card, 409-410, 409f Altrnate testing in, 165 retinoscopy n, 163
97-99, 98f excess of, 44-45, 45t cover test, 108-109, 109f, saccades in, 147-148 scotoma in,
facility of, 45-46, 46f, 47t, 48t 1091,230, 230f Altrnate 164 screening for, 165-166 Snellen
developmental norms of, 48 fixation, on amblyoscope, chart testing in, 149-151, 150f spatial
monocular vs. binocular, 47 ill- 331 Alternation theory, of uncertainty in, 147 strabismic, 144
sustained, 48-49, 49t infacility of, sensory fusin, treatment of, 279-320. See a/so
49 16, 16f Amblyopia therapy tumbling
insufficiency of, 40-44, 411, 42t, 49 Amblyopia, 143-166. See a/so Ambly- f card testing in, 153-154,
lag of, 43-44, 43f, 44f, 44t opia therapy accommodation in, 155f
monocular estmate method retinos- 148 Amsler grid testing n, 164 vergence responses in, 148 visual
copy measurement of, 43-44, 44f anisometropic, 144-145, 313-320 of acuity testing in, 149-159. See
Nott dynamic retinoscopy measure- arrest, 146 Bailey-Lovie chart a/so Visual acuity, testing of
ment of, 43, 43f relative, 42-43, 42t, testing in, 151, visual field testing in, 164 visually
49 stamina of, 48-49, 49t 151f evoked potentials in, 158-
Accommodation training, 462-466, case history in, 148-149, 149t 159, 158f, 159f visuoscopy in,
463t. See a/so Accommodation classification of, 144-145, 145t, 160, 160-161, 162f Amblyopia therapy,
accommodative tromboning in, 465 160t 279-320, 540. See
case study of, 472-473, 473f Hart contrast sensitivity in, 146-147 a/so Amblyopia in adult
Chart near-far rock technique cortical dysfunction in, 147 anisometropic amblyopia,
in, 533-537, 534f-536f jump definition of, 143 developmental 313-318 in anisometropic
focus in, 465 lens rock technique aspects of, 145-148, and strabismic
in, 465-466, 146t amblyopia, 318-320
537-538, 537f sequence of, electroretinography in, 165 of anomalous retinal correspondence
543 Accommodative esotropa, 215- extinction, 146 eye disease and,309-310 case studies
220. evaluation in, 163-165 fixation of, 313-320 levodopa in, 291
See a/so Strabismus high AC/A ratio, pattern in, 147, 159-163, monocular fixation training in, 293-
217-220 miotics in, 219-220 optical 160f, 160t, 161f, 162f 300, 293t afterimage transfer
treatment of, 218-219, 218f surgery Haidinger brush testing in, 161-163, training for,
in, 220 visin training in, 218-219 162f 301-304 Ann Arbor Tracking
refractive, 216-217, 216t optical image degradation, 145, 145t infant Program for,
treatment of, 216-217, 217f visual acuity assessment for, 296-297, 298f eye-hand
154, 156-158, 157f coordination techniques
interferometry in, 159, 160f for, 294-297, 295f, 296f, 297f,
isoametropic, 145 meridional, 298f foveal tag techniques for,
145 300-305,
monocular color visin testing in, 301 f, 302f, 305f
165
596 Index

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

~^2M ts^-3 Spllt-tield eftect, 172, 174f 185


i n . f _

-m\m\l^^A^
1 . . t

' er
al
,
1
0
s . 4

mixecfdominancy in, 133


,

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

Zinn, annulus of, 5


Zone of clear, single binocular visin
(ZCSBV), 72-76, 73f, 74f interpretation of, 74-75,
75f normal with symptoms,,96-97,
96f restricted, 96, 96f

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