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Binocular Vision exercises that work

Dr Catherine Porter PhD MCOptomPGCertHE SFHEA

Senior Lecturer in OptometryUniversity of Manchester

Learning Objectives• The ability to manage patients with an anomaly

of binocular vision.

• How to identify patients who need eye exercises for decompensating phorias, convergence problems, or anomalies of accommodation

• The ability to prescribe exercises to remedy simple binocular vision problems.

Orthoptic exercises: a brief history

Helveston (2005)

Dr Catherine Porter

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History and Symptoms

• Diplopia• Frontal headaches• Asthenopia• Eye strain• Poor near vision• Near work avoidance• Words wobbling or moving

Alleviate symptoms

• Decompensating

heterophoria

– Eso/ Exo

• Convergence

Insufficiency

– Reduced NPC

– Reduced positive fusion

range

– Monoc A of A normal

but reduced binocularly

• Accommodation

Insufficiency

– Blurred NV

– Reduced A of A for age

• Accommodative

Infacility

– Problems changing focus

D/N

– < 8cpm on +/-2.00DS

flippers

Dr Catherine Porter

Do exercises work?• Convergence insufficiency treatment trial

(http:/www.optometry.osu.edu/research/CITT/8581.cfm)– Increases in accommodation and accommodative facility (Scheiman et al.,

2011)– Improvement in symptoms, NPC and fusion (Scheiman et al., 2010)– Office based therapy (with home reinforcement) more successful than home

based (Scheiman, Gwiazda, Li (2011) – Cochrane review; Scheiman et al., 2011)

• Normalisation of NPC in 80% CI (Adler 2002)

• Retrospective examination of CI and decompensating phoria (Aziz et al 2006)– Normalisation of NPC

• 86% exo; 33% eso– Normalisation of fusion range

• 68% exo (BO); 11% eso (BI)– Asthenopic symptoms reduced

• 90% exo; 54% esoDr Catherine Porter

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Pre-requisites

• Refractive error corrected• Equal VA• Functional– BV or potential for BV– Low density of suppression

• Cooperation (regular attendance)• Old enough to understand instructions• <25^• Healthy

Dr Catherine Porter

Stages1. Overcome suppression and awareness of

diplopiaStimulus to fuse

2. Extension of fusion rangePositive (exo)/ negative (eso)

3. Improvement of relative convergence reserves

Dr Catherine Porter

Physiological diplopia• Must be taught before exercise regime• Ensures binocularity and vergence control

Dr Catherine Porter

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How to make Brock String

Extension of fusion range: Brock String

• Physiological diplopia & BSV at more then 33cms

• Useful for severe CI

Patient

Patients’ nose

Dr Catherine Porter

Extension of fusion range: Dot card

• Used early in regime• Awareness of physiological diplopia• Ensure dots remain clear and single

Patients’ viewDr Catherine Porter

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Dot card

• Advantages– Effective– Portable– Cheap and easy to use

• Disadvatages– Convergence must be better that approx 30cms

Dr Catherine Porter

Extension of relative convergence range: Stereograms

• End of treatment

Pen proximal = positive relative convergence (exo)

Pen distal = negative relative convergence (eso)

Dr Catherine Porter

Extension of relative convergence range: Stereograms

• Aim = achieve 3 clear cats/buckets/circles

– Start with four– Progress to 3– Improve clarity– Pen, then unaided, move

card or pen closer

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Extension of relative convergence range: Stereograms

• Advantages– Portable– Positive and negative relative convergence

• Disadvantages– Difficult– Higher level of understanding – older

children/adults

Dr Catherine Porter

Accommodative Facility

Hart Chart

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Points to remember

• Intractable diplopia– Only treat if BV present

• Frequency– ~3 x 5 mins per day (little and often)

• Warn symptoms may worsen before improvement felt

• Accomodative spasm (CI)– Relaxation exercises

• Close eyes/look in distance/- fusion/-relative fusion

Dr Catherine Porter

Follow up visits• ~ every 2 - 4 weeks

• Questions– Symptoms? Any improvement?– How often doing exercises/which ones?– Ask patient how to demonstrate exercises

• Important tests– Binocular visual acuity (BVA)– Prism fusion range– Stereo tests– CT– Convergence (If CI)– Accommodation

Dr Catherine Porter

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Discontinuation• When symptom free with good level of control– Optimum BVA– Good fusion reserves

• No improvement after ~4-6 wks

• Convergence/accommodative spasm– Exercises stopped– Improve negative fusion range (BI prisms/ - relative fusion)

Dr Catherine Porter

Follow up visits• Everything OK (symptoms and objective tests):

– continue exercises at half rate for 2 weeks and recheck.

• Better but not OK:– continue exercises for 2 weeks and recheck– Additional exercises

• Exercises done but no improvement after 4-6 wks:– review diagnosis, check motility, refer?

• Exercises not done:– alternative management? Letter of information to GP?

Dr Catherine Porter

Prescribing Prism

• Intensive orthoptic therapy is the treatment of choice for convergence insufficiency. Pencil push-ups and use of accommodative targets have a role in the treatment of convergence insufficiency when used as part of a more intensive orthoptic program. Base-in prism glasses should be reserved for reduction of symptoms in the presbyopic population.

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Case Discussion

• Diagnosis• Management• Exercises• Frequency• Follow up

Any Questions?

• Email• Catherine.Porter@manchester.ac.uk