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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 Page 1 of 8 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 Page 2 of 8 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 Page 3 of 8 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?) Page 4 of 8 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 Page 5 of 8 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 Page 6 of 8 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 Page 7 of 8 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 Page 8 of 8