A COMMON SENSE APPROACH TO A COMMON SENSE APPROACH TO THE PROBLEMS OF TWO EYESTHE PROBLEMS OF TWO EYES

MARK WOODWARD, O.D.MARK WOODWARD, O.D.

Why This Talk?Why This Talk?

Binocular disorders are numerous Binocular disorders are numerous and complex.and complex.

They involve many different areas of They involve many different areas of knowledge includingknowledge including– Muscular anatomyMuscular anatomy– NeuroanatomyNeuroanatomy– Sensory adaptationsSensory adaptations– Multiple disease processesMultiple disease processes

 General approach to diplopia.

Danchaivijitr C , Kennard C J Neurol Neurosurg Psychiatry 2004;75:iv24-iv31

©2004 by BMJ Publishing Group Ltd

SO CAN WE REDUCE SO CAN WE REDUCE THIS COMPLEXITY AND THIS COMPLEXITY AND

CREATE A SIMPLE CREATE A SIMPLE PROTOCAL FOR A PROTOCAL FOR A

BINOCULAR WORK UP?BINOCULAR WORK UP?

YES!YES!

Who’s afraid of Marty?Who’s afraid of Marty?

The Two Natures of The Two Natures of DisordersDisorders

MorbidMorbid– Infiltrative diseaseInfiltrative disease– Vascular diseaseVascular disease– Neoplastic diseaseNeoplastic disease– Auto immune Auto immune

diseasedisease– Trauma, injuryTrauma, injury

– Tissue damage, you Tissue damage, you image it, find itimage it, find it

FunctionalFunctional– Healthy tissueHealthy tissue– Just not working Just not working

rightright

– Sometimes even Sometimes even the cover testing is the cover testing is normalnormal

Our history and work up need Our history and work up need to differentiate between the to differentiate between the

two types of disorderstwo types of disordersandand

perhaps provide enough perhaps provide enough information to provide a information to provide a

remedy or a plan.remedy or a plan.

So where are you?So where are you?Can you define and/or Can you define and/or

test……….test………. Lids/PupilsLids/Pupils

APD?APD? DuctionsDuctions VersionsVersions PhoriaPhoria TropiaTropia VergenceVergence CUCCUC ACTACT

Estimate deviations Estimate deviations Prism neutralization Prism neutralization

in primary gazesin primary gazes Prism neutralization Prism neutralization

in lateral and in lateral and vertical gazesvertical gazes

ComitancyComitancy Measure a fusion Measure a fusion

range? range?

Some assessment Some assessment questions?questions?

Functional binocular complaints are more Functional binocular complaints are more common than morbid ones.common than morbid ones. T or FT or F

The alternate cover test defines the The alternate cover test defines the phoria.phoria. T or FT or F

A prism shifts the image towards its’ apex A prism shifts the image towards its’ apex for both the patient and the examiner. for both the patient and the examiner. T or F T or F

The near and far cover tests measure the The near and far cover tests measure the same thing.same thing. T or F T or F

Prism Simulations of Prism Simulations of DisordersDisorders

8^ BI @ DV full field – complete CN VI8^ BI @ DV full field – complete CN VI Now look at near, single? So where do we test eso’s?Now look at near, single? So where do we test eso’s?

8^ BI @ DV right field – partial CN VI8^ BI @ DV right field – partial CN VI 3^ to 4^ BU OD – right CNIV ie S.O. palsey3^ to 4^ BU OD – right CNIV ie S.O. palsey 2^ to 3^ BU OD – early Graves, morbid CNIV 2^ to 3^ BU OD – early Graves, morbid CNIV

or or decompensating functional CNIVdecompensating functional CNIV BO build up at nearBO build up at near

– Low, no problemLow, no problem– Medium, Conv. Insuff. strain but singleMedium, Conv. Insuff. strain but single JD’s? JD’s?– High, swimming letters, CI at fusion limitsHigh, swimming letters, CI at fusion limits

Previous History?Previous History?

TraumaTrauma StrabismusStrabismus SurgeySurgey PatchingPatching Eye exercisesEye exercises ThyroidThyroid AmblyopiaAmblyopia

History of Present IllnessHistory of Present Illness

Diplopia…Eyestrain…Head ache…Blur Diplopia…Eyestrain…Head ache…Blur

Onset, acute or gradualOnset, acute or gradual Affected gaze(s)Affected gaze(s) Distance and/ or nearDistance and/ or near Intermittent vs. constantIntermittent vs. constant Monocular/ binocularMonocular/ binocular Associated factorsAssociated factors Images horizontal, vertical, diagnalImages horizontal, vertical, diagnal

The classic functional The classic functional complaint or questioncomplaint or question

How long can you read before How long can you read before your eyes start to bother you?your eyes start to bother you?

THE WORK UPTHE WORK UP

Lids, orbits, pupils. APD target?Lids, orbits, pupils. APD target? Ductions or versions. Proper target?Ductions or versions. Proper target?

-1 -4 80% 0%

CNP or NPC4”/8”

Work Up Cont’Work Up Cont’

A couple definitionsA couple definitions– Phoria- a resting posture without Phoria- a resting posture without

binocular opportunitybinocular opportunity Defined by the ACT, the fundamental Defined by the ACT, the fundamental

measuremeasure

– Tropia- an actual turn under normal Tropia- an actual turn under normal binocular opportunitybinocular opportunity Defined by the UCT or CUCDefined by the UCT or CUC

Vergence Reflex – the ability to converge or diverge the lines of sight to fixate on objects at various distances.

Fusion Range – the amount of prism interference needed to break the

lines of sight apart from a fixation point.

We use prisms to measure deviations, to measure the strength of compensating fusional reflexes, and to correct deviations.

Tropia, Phoria and the Tropia, Phoria and the Vergence ReflexVergence Reflex

ACTccACTcc 20^ XP20^ XP CUCccCUCcc 14^ XT14^ XT

Where did the 6^ of difference come Where did the 6^ of difference come from?from?

Cover testingCover testing Always start with the distance of the complaint.Always start with the distance of the complaint. Step #1: CUCcc in primary gazeStep #1: CUCcc in primary gaze only and only and

document eye, direction and magnitude of tropia document eye, direction and magnitude of tropia if found. Estimate or neutralize with prism.if found. Estimate or neutralize with prism.

Step#2: ACTcc Step#2: ACTcc in primary, right & left gazes and in primary, right & left gazes and document direction and magnitude of the phoria document direction and magnitude of the phoria in each gaze. Estimates or neutralize with prism.in each gaze. Estimates or neutralize with prism.

Step #3: If the difference between any of the Step #3: If the difference between any of the three measures isthree measures is– >5^>5^ (noncomitant) you are done. Congratulations! (noncomitant) you are done. Congratulations!– = 5^ or less= 5^ or less(comitant) do(comitant) do BI and BO fusional reserves in BI and BO fusional reserves in

that order. Record break and recovery. that order. Record break and recovery. Congratulations, you are done.Congratulations, you are done.

This protocal is fairly comprehensive for morbid and functional horizontal disorders.

Verticals will require further evaluation by your physician or specialist i.e. Park Three Step test for isolating vertical muscles.

Case #1Case #1

58yo wm c NIDDM co fleeting horizontal 58yo wm c NIDDM co fleeting horizontal diplopia when driving.diplopia when driving.– Pupils, lids, versions, orbits all WNLPupils, lids, versions, orbits all WNL– CUCCUC 0T0T– ACT 8 EP------4 EP----------0PACT 8 EP------4 EP----------0P– Non-comitant, you are done.Non-comitant, you are done.– Physician goes on to DX mild diabetic R Physician goes on to DX mild diabetic R

CNVI and frosts the temporal 2/3 of the CNVI and frosts the temporal 2/3 of the right lens.right lens.

– Why wasn’t the patient troped in prim. Why wasn’t the patient troped in prim. gaze?gaze?

Case #2Case #2 38 yo bf c Hx of mild uncorrected 38 yo bf c Hx of mild uncorrected

hyperopia and OTC readers at near hyperopia and OTC readers at near complains of fleeting diplopia when complains of fleeting diplopia when driving.driving.– Pupils, lids, versions, orbits WNLPupils, lids, versions, orbits WNL– CUCCUC 0T0T– ACTACT 4 EP---------5EP----------4EP 4 EP---------5EP----------4EP– ComitanceComitance BI BI 2/02/0 BO 16/12 BO 16/12– Physician Dx’s functional esophoria and Physician Dx’s functional esophoria and

Rx’s full plus multifocal with or without BO Rx’s full plus multifocal with or without BO prismprism

Case #3Case #3

23yo HM in graduate school complains of 23yo HM in graduate school complains of “jumbling” words after reading for 20 “jumbling” words after reading for 20 minutes. Cycloplegia Plano/Planominutes. Cycloplegia Plano/Plano– Pupils, lids, versions, orbits all WNLPupils, lids, versions, orbits all WNL– CUC at nearCUC at near 0T0T– ACT at nearACT at near 5XP-------6XP--------6XP5XP-------6XP--------6XP– ComitanceComitance BI’ 18/16 BO’ 4/2BI’ 18/16 BO’ 4/2– Physician Dx’s convergence insufficiency Physician Dx’s convergence insufficiency

and prescribes NV prism Rx and prescribes NV prism Rx

Case #4Case #4 68 yo WM with Hx of HBP presents with 68 yo WM with Hx of HBP presents with

sudden onset painful double visionsudden onset painful double vision– OD pupil dilated, no APD. Orbits normal.OD pupil dilated, no APD. Orbits normal.– OD no adduction, Right lid droops.OD no adduction, Right lid droops.– CUC Large right hypo XT estimates 25^ XTCUC Large right hypo XT estimates 25^ XT– ACTACT 10^ XP------20^ XP------35^ XP10^ XP------20^ XP------35^ XP– Noncomitant, you are done.Noncomitant, you are done.– Physician recognizes right CNIII palsy with Physician recognizes right CNIII palsy with

pupil involvement. Precise measure of pupil involvement. Precise measure of vertical deviation is not material. Patient is vertical deviation is not material. Patient is referred for immediate evaluation to R/O referred for immediate evaluation to R/O posterior communicating artery aneurysm.posterior communicating artery aneurysm.

DemonstrationsDemonstrations

CUC PGCUC PG

ACT PG,RG,LGACT PG,RG,LG

Fusion RangeFusion Range BIBI

BOBO

From the Doctors From the Doctors PerspectivePerspective

HX, lids, pupils, versions……………Great!HX, lids, pupils, versions……………Great! ACT in primary and lateral gazes ACT in primary and lateral gazes

provides useful information for morbid provides useful information for morbid and functional disorders. and functional disorders.

Comitant deviations deserve BI and BO Comitant deviations deserve BI and BO fusion ranges to Dx functional disorders fusion ranges to Dx functional disorders like convergence insufficiency and like convergence insufficiency and decompensating phorias..decompensating phorias..

The Cover Test ‘Three Step’The Cover Test ‘Three Step’

Step #1: CUCcc in primary gazeStep #1: CUCcc in primary gaze onlyonly

Step #2: ACTcc in primary, right and Step #2: ACTcc in primary, right and left left gazegaze

Step #3: If the difference between any Step #3: If the difference between any of of the three measures is = or less the three measures is = or less than 5^ do BI and BO fusional than 5^ do BI and BO fusional rangesranges

Assessment AnswersAssessment Answers

Functional binocular complaints are Functional binocular complaints are more common than morbid ones.more common than morbid ones.

TT The alternate cover test defines the The alternate cover test defines the

phoria.phoria. TT A prism shifts the image towards its’ A prism shifts the image towards its’

apex for both the patient and the apex for both the patient and the examiner. examiner. TT

The near and far cover tests measure The near and far cover tests measure the same thing.the same thing. FF

Web Based ResourcesWeb Based Resources

Slideshare.netSlideshare.net Youtube- type in tropia or phoriaYoutube- type in tropia or phoria www.ophthobook.comwww.ophthobook.com/videos/videos

– Weak in the phoria definitionWeak in the phoria definition Eyeontechs.com/new/?p=30Eyeontechs.com/new/?p=30

– A nice cover test simulatorA nice cover test simulator Misrepresents the intermittent strabismusMisrepresents the intermittent strabismus