Download Plus, Minus, Prism, and Therapy: Managing Accommodative and

Plus, Minus, Prism, and Therapy: Managing Accommodative and Vergence Dysfunction
American Academy of Optometry Meeting, Boston 2011
Kristine B. Hopkins, OD, MSPH, FAAO
University of Alabama at Birmingham School of Optometry
[email protected]
Case History
Onset: Sudden vs. gradual; Longstanding vs. recent
Frequency: every day, only school/work days, mornings, afternoons
Duration: minutes vs. hours
Eliciting factors: associated with near work, computer work, lighting, etc.
Pertinent medical history/medications: accommodative side effects?
Symptom Checklist or patient/parent survey
Functional Vs. Organic Lesion
Etiology
Symptoms
Signs
Functional
Reduced function not related to
organic lesion
Typically longstanding without precise
onset.
Typically bilateral
Not associated with neurological loss,
systemic illness, or medications
Organic
Neurological lesion or other organic defect
source of decreased function
Typically sudden onset, often severe
May be unilateral or bilateral
Typically associated with other neurological
signs, systemic illness, or medication use.
EOM palsy, pupil abnormality, visual field
defect, ptosis.
Initial exam should rule out significant refractive error and ocular pathology. If significant
refractive error present, Rx and return to re-test BV and accommodation with new Rx (4-6
weeks later).
Significant Refractive Error (patients 6 years and older):
Myopia
Hyperopia
Astigmatism
Aniosmetropia
-1.00D or greater
+2.50D or greater*
-1.00D or greater
1.00D difference or greater
*May prescribe for lower amounts of hyperopia in presence of BV/accomm dysfunction
AAO Meeting 2011: Hopkins
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Binocular, Accommodative, and Ocular Motor Testing Battery and Norms
BV Alignment and Vergences
Test
Cover Test
Age
Any
AC/A
CA/C
Smooth Vergences
Any
Any
Any
BI/BO ranges in
phoropter with Risley
Prisms
Condition
Near
Distance
Near BO
Near BI
Distance BO
Distance BI
Expected Value
3 XP (±3)
1 XP (±1)
3/1 to 5/1
0.5D per 6Δ
17/21/11
13/21/13
9/19/10
X/7/4
23/16
12/7
19/14
13/10
11/7
7/4
15 cpm
6 cm (minimum 10cm)
5/7 cm (minimum 10cm)
7/10 cm
Step Vergences
Child 7 to 12
BI/BO ranges with
prism bar
Adult 12
Vergence Facility
Any
Near BO
Near BI
Near BO
Near BI
Distance BO
Distance BI
3BI/12BO
Children
Adults
Adults
With accomm tgt
With accomm tgt
With R/G tgt
Fused prism
NPC
Accommodation
Test
Amplitude
Monoc. Facility
NRA
Age
Any
8-12 yo
13-30 yo
8-12 yo
13-30 yo
13-30 yo
Any
PRA
Accom Response
Any
Any
Binoc Facility
AAO Meeting 2011: Hopkins
Condition
Any
±2.00 flipper
±2.00 flipper
±2.00 flipper
Scaled flipper
±2.00 flipper
MEM
Expected Value
Minimum=[15-(age/4)]-2
7 cpm (±2.5): at least 4 cpm
11 cpm (±5): at least 6 cpm
5 cpm (±2.5): at least 2 cpm
10 cpm
Approx 8 cpm
+2.00 to +2.50
-2.37 to –3.37
+0.25 to +0.50
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Accommodative Insufficiency
Associated with near work: blur (text “comes in and out of focus”),
Symptoms
Signs
Critical Tests
Treatment Options
headaches, tired or sore eyes, poor reading comprehension, fatigue,
blinking or squinting to read.
Reduced amplitude of accommodation
 [15-(age/4)]-2
May or may not show higher lag on MEM
Accommodative Amplitude
 Push-up (highest value and lowest repeatability)
 Pull-away
 Minus lens amps (lowest value but best repeatability)
 Objective amps with retinoscope (over estimates amps)
Additional plus at near
 Plus build up—subjective
 MEM method—for patients with high lag on MEM, add plus
until MEM normalizes
 NRA/PRA midpoint—accounts for vergence ranges but doesn’t
always indicate need for additional plus
 BCC—subjective
For young patients: Rx FT at lower pupil margin, PAL 2-3cm high, or
NVO specs (multifocal CL’s?)
Vision therapy
 Often best choice if AI is also associated with BV dysfunction
Accommodative Infacility
Symptoms
Signs
Critical Tests
Treatment Options
AAO Meeting 2011: Hopkins
Blur (may be distance or near), difficulty copying from the board,
headaches, fatigue, eye strain
Reduced monocular and binocular accommodative facility
 Difficult with + and – sides of flipper
May also show decreased NRA/PRA
Monocular Accommodative Facility
 Reduced binocular facility not specific to accommodative
infacility (may also indicate poor vergences)
Additional plus at near if NRA is high enough (see AI)
Vision therapy
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Accommodative Excess/Spasm
Symptoms
Signs
Critical Tests
Treatment Options
Blur (may be distance or near) worse after prolonged near work,
headaches, eye strain, fatigue, diplopia (if associated with ET)
 Neutral or lead with MEM
 Difficulty clearing plus with monocular facility testing
 Reduced NRA
 Dry ret/auto may show more minus than wet
 MEM
 Monocular accommodative facility
 Wet retinoscopy
Vision Therapy
Cycloplegic agents for extreme spasm
 Spasm of the near reflex: lead on MEM, ET, and pupil miosis
 Consider 1% Atropine OU twice/week with near add (wean
over time)
Bifocal lenses not indicated (low NRA—patient will not accept plus)
Binocular Vision Dysfunction: Making the Diagnosis
 Begin with measurement of ocular alignment at distance and near to make Duanne’s
classification and generalization about AC/A.
 Look at tests that belong to compensating testing group for depressed findings to
support diagnosis
o For an exo deviation, the tests that measure Positive Fusional Vergence (PFV)
findings would need to be normal or high to prevent symptoms. Depressed PFV
findings along with symptoms support the diagnosis and need for treatment.
o For an eso deviation, the tests that measure Negative Fusional Vergence (NFV)
findings would need to be normal or high to prevent symptoms. Depressed NFV
findings along with symptoms support the diagnosis and need for treatment.
 If symptoms and signs are present, recommend treatment
Deviation
Exo Deviation
Compensating Group
Positive Fusional Vergence Group
Eso Deviation
Negative Fusional Vergence Group
AAO Meeting 2011: Hopkins
Tests
BO (PFV) ranges (smooth or step)
BO ability with vergence facility
NPC
NRA
Binocular Plus with accommodative facilty
MEM (may show lead?)
BI (NFV) ranges (smooth or step)
BI ability with vergence facility
PRA
Binocular minus with accommodative facility
MEM (may show lag?)
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Expanded Duanne’s Classifications
Cover Test
Greater eso at near
than distance
Greater exo at
distance than near
Greater eso at
distance than near
Greater exo at near
than distance
Similar eso at
distance and near
Similar exo at
distance and near
Nearly ortho at
distance and near
Duanne’s Classification
Convergence Excess (CE)
AC/A
High
Supporting Signs
Reduced NFV findings at near
Divergence Excess (DE)
High
Divergence Insufficiency (DI)
Low
May show reduced PFV findings at
distance (but often normal)
Reduced NFV findings at distance
Convergence Insufficiency (CI)
Low
Reduced PFV findings at near
Basic Eso
Normal
Basic Exo
Normal
Reduced NFV findings at distance
and/or near
Reduced PFV findings at distance
and/or near
Reduced PFV and NFV at distance
and/or near
Fusional Vergence Dysfunction Normal
Convergence Excess
Symptoms
Signs
Critical Tests
Treatment Options
AAO Meeting 2011: Hopkins
Headaches and eye strain with near work, blur, diplopia at near, fatigue
with reading, slow reading, poor reading comprehension, words moving
on page, avoidance of reading
 Greater eso at near than distance
 High AC/A
 Low NFV group findings
 May show high lag with MEM
 Cover Test
 NFV group tests
 MEM
Additional Plus at near
 High AC/A responds well to low amounts of plus
 Rx amount of plus that reduces near phoria to near ortho
(maximum plus to correspond with working distance)
Base Out Prism
 May be needed if small eso present at distance and near add
still leaves residual eso with symptoms
Vision Therapy
 Not generally first line of treatment. May be necessary of
optical management alone does not resolve symptoms or if
patient unable/unwilling to wear optical correction
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Divergence Excess
Symptoms
Signs
Critical Tests
Treatment Options
Cosmetic concerns about outward eye turn (often IXT), rarely diplopia,
rarely near point symptoms
 Parent/patient report of IXT (may not manifest with CT)
 Greater exo at distance than near
 PFV and NFV ranges may be normal at distance and near
 May show suppression or ARC at distance when the eye is XT
 High AC/A by calculation but may not be truly high with gradient
 Cover Test
 PFV data (although may be normal)
 May do prolonged CT to rule out Pseudo-DE
Over minus lenses
 Recommended for young patients (under 6) with true high AC/A
 Trial over minus in office
 Rx for FTW generally up to -2.50 over minus
Vision Therapy
 DE IXT’s generally respond well to VT and often first line of tx
 Emphasize diplopia awareness and vergence ranges
Prism
 Horizontal prism not generally beneficial
Occlusion
 FT occlusion for as long as 2 months may decrease suppression
and improve fusion
 More popular with ophthalmology
Surgery
 Considered for very large (>35-40), frequent deviations that fail
to respond to more conservative treatment
Divergence Insufficiency
Symptoms
Signs
Critical Tests
Treatment Options
AAO Meeting 2011: Hopkins
Longstanding intermittent diplopia at distance, headaches, ocular
fatigue, difficulty focusing from far to near
 Greater eso at distance than near (phoria or tropia)
 Reduced NFV group findings at distance
 Cover Test
 NFV group tests (at distance)
 EOM’s (rule out 6th Nerve Palsy)
Prism
 BO prism often treatment of choice for low magnitude deviation
Vision Therapy
 Improving NFV ranges and vergence facility often helpful
Surgery
 Last resort if deviation cannot be managed with prism and VT
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Convergence Insufficiency
Symptoms
Signs
Critical Tests
Treatment Options
Symptoms occur while doing near work: headaches, eye strain, blurred
vision, diplopia, movement of print, poor reading comprehension
 Greater exo at near than distance
 Receded NPC
 Reduced PFV group findings
 Low AC/A
 Cover Test
 NPC
 PFV group tests
Vision Therapy (office based)
 Most effective treatment for CI
 Emphasize PFV’s and NPC as well as accommodative amps and
facility
Vision Therapy (home based)
 Use of HTS or similar computer system may be beneficial but will
likely take longer than office based treatment
 Pencil push-up therapy alone is not effective
BI Prism
 Not generally effective for long term treatment of CI
Basic Eso
Symptoms
Signs
Critical Tests
Treatment Options
AAO Meeting 2011: Hopkins
Symptoms may be associated with distance and/or near work:
headaches, eye strain, blur, diplopia, poor reading comprehension
 Similar eso at distance and near
 Reduced NFV group findings at distance and near
 MEM may show higher than normal lag
 Cover test
 NFV group tests
 MEM
 EOM’s (rule out 6th Nerve Palsy)
Additional Plus at Near
 Although AC/A normal, low amounts of plus may reduce EP
enough to eliminate near symptoms
 Rx least amount of plus necessary
BO Prism
 BO relieving prism should be considered when plus not well
tolerated or not effective.
 Eso’s generally respond more favorably to prism than exo’s
Vision Therapy
 Therapy to improve NFV ranges at near and then distance often
helpful
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Basic Exo
Symptoms
Signs
Critical Tests
Treatment Options
Symptoms may be present with near or distance work: eye strain,
headaches, blur, diplopia, poor reading comprehension, movement of
print
 Similar exo at distance and near
 Reduced PFV group findings at distance and near
 Receded NPC
 Cover test
 PFV group tests
Vision Therapy
 Responds favorably to therapy (similar program to CI)
 In-office therapy recommended when possible, home therapy
may also be effective
Prism
 BI relieving prism may be considered
 If vertical deviation present, vertical prism may be helpful
Surgery
 Rarely necessary but may be considered for large deviations that
do not respond completely with therapy and/or prism
Fusional Vergence Dysfunction
Symptoms
Signs
Critical Tests
Treatment Options
Symptoms associated with near work: Headaches, eye strain, blur, poor
reading comprehension, avoidance of reading
 Normal phoria at distance and near
 Reduced BO and BI ranges at near and/or distance
 Reduced PRA and NRA
 Reduced binocular accommodative facility but normal
monocular facility
 Fusional vergence ranges (BI and BO)
 Accommodative facility testing
 NRA/PRA
Vision Therapy
 Training improves vergence ranges
 In-office vs. home
Reference: Scheiman M, Wick B. Clinical Management of Binocular Vision: Heterophoric, Accomodative, and Eye
Movement Disorders, 3 ed: Lippincott Williams & Wilkins, 2008
AAO Meeting 2011: Hopkins
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