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Major Review
Prisms in clinical practice
ABSTRACT
Prisms are used in diagnosis and Therapy of Ophthalmic disorders. Prismotherapy provides symptomatic relief not only in many kinds of squints,
but also in non strabismic conditions like convergence insufficiency, nystagmus, heminopia etc. One of the most important therapeutic skill we
have acquire in this direction, is the localisation of such clinical needs and the timely use of the wonderful therapeutic functions of prisms for
the relief of such conditions. Thin Fresnel prisms are now more used in clinical practice.
Keywords: Fresnel prism, hemianopic spectacles, prism base, prism diopter, vertical diplopia
INTRODUCTION Since the light still falls on the macula of the other eye,
double vision would be produced. Consequently, the eye with
Only few ophthalmologists prescribe prisms now. Is it due prism base directed outward will deviate inward so that the
to lack of awareness among novice? or other reasons? We deflected light falls on the macula once again and binocular
don’t know! However, it a fact that prisms are really useful vision is made possible.
and become the only way of salvation in many ophthalmic
clinical situations, if their secrets are understood, judiciously The maximum effort which can be put in this way
used, and properly prescribed. This article is an attempt to (the capacity to maintain fusion) is measured by the
revive interest in this direction. strongest prism with which diplopia is not produced.
Prismatic power of even 30–60 Δ can be overcome normally
HOW PRISMS FUNCTION by convergence and 10–15 Δ divergence, and 2–4 Δ by
circumvergence. The measurements of this artificially
Prism is a transparent, solid, triangular refracting medium produced diplopia (vergence power) are important in
with a base and apex. Its apical angle determines the power diagnosis and treatment of muscular in balance.
of prism. A prism of one prism diopter power (Δ) produces
an apparent displacement of one centimeter to an object Even though the light deviates toward the base of prism and
situated one meter away. Light entering the prism will deviate eye deviates to the apex of prism, in practice, we denote
toward its base. However, image appears shifted to the apex, the prisms in terms of the direction of their base ‑ in, out,
and the eye examined or treated tend to deviate toward its up, or down.
apex. This is how prisms function and manipulate the special • Thus, to bring an eye inward, keep the base of prism
location of image clinically [Figure 1]. directed outward in front of the eye
RESPONSE OF EYE TO PRISM J. Antony
Department of Ophthalmology, Sree Gokulam Medical College
If a prism is placed before one eye, with its base directed and Research Foundation, Thiruvananthapuram, Kerala, India
outward, the light rays from object will be deflected
Address for correspondence: Dr. J. Antony,
outward (to the base) and fall on the retina outer to fovea. Sree Gokulam Medical College and Research Foundation,
Thiruvananthapuram, Kerala, India.
E‑mail:
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10.4103/kjo.kjo_84_17 How to cite this article: Antony J. Prisms in clinical practice. Kerala J
Ophthalmol 2017;29:79‑85.
© 2017 Kerala Journal of Ophthalmology | Published by Wolters Kluwer - Medknow 79
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Antony: Prisms in clinical practice
Figure 2: Response of eye to prism
Figure 1: Optics of prism
Figure 3: Detection of prism
Figure 4: Trial set
Figure 5: Prism in trial set
Figure 6: Loose prisms in prism set
Figure 8: Vertical prism
• To make an eye deviate outward, use base‑in (BI) prism
• To bring down an eye, base‑up prism is needed
• To take up an eye, base‑down prism is used.
A base‑out prism is an adducting prism, and a BI prism is an
Figure 7: Fresnel prism abducting prism [Figure 2].
80 Kerala Journal of Ophthalmology / Volume 29 / Issue 2 / May‑August 2017
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Antony: Prisms in clinical practice
Figure 9: Horizontal
Figure 10: Right divergent squint measured with prism bar
Figure 12: Base‑in prism for treatment of convergence insufficiency
Figure 11: Right divergent squint corrected with prism
vii. In the management of glaucoma and retinitis
DETECTION OF PRISM pigmentosa (RP)
viii. Prisms in treatment in bedridden patients
To detect the presence of a prism, hold it over an object (eg: ix. Prisms in paralytic squint (diplopia)
cross line), the portion of line under the prism will appear x. Prisms in contact lens (CL) correction.
broken and displaced towards its apex [Figure 3].
MEASUREMENT OF SQUINT
TYPES OF PRISMS
Apart from other methods of measurement of squint, the
Prisms are available as loose prism in glass trial set and prism angle of deviation can be measured by placing prisms of
set, and also as prism bars and Fresnel prism [Figures 4-9]. increasing strength in front of fixing the eye with their base
1. Loose prisms in the glass trial set from ½ Δ to 12 Δ and inward in exodeviation and base outward in esodeviations
in prism set from 5 Δ to 60 Δ powers until the corneal reflection of the squinting eye becomes
2. Prism bars (horizontal and vertical) from 1 Δ to 40 Δ centered. The strength of prism necessary to achieve this is
powers the amount of squint (Krimsky test) [Figure 10]. In modified
3. Fresnel prism ‑ thin prisms arranged in a plastic sheet, Krimsky test, prisms are placed in front of the deviating eye.
in powers from 1 Δ to 40 Δ. However, there is some difficulty in seeing the corneal reflex.
CLINICAL USES OF PRISMS PRISMS IN TREATMENT OF PHORIAS
I. Diagnostic indications Prisms are considered in the treatment of phorias only after
1. Prisms form part of many ophthalmic equipment correcting any precipitating causes such as general weakness,
such as gonioscopes, keratometers, applanation convergence insufficiency, and refractive errors.
tonometers, and ophthalmoscopes
2. For assessment (measurement) of squint Orthoptic exercise
II. Therapeutic indications [Figures 13-18] For giving exercise to weak muscles, prisms with their
i. Treatment of phorias base toward the direction of deviation (adverse prism) are
ii. Treatment of tropias tried [Figure 12].
iii. Convergence insufficiency
iv. Divergence insufficiency Prism treatment
v. Nystagmus When the above treatments fail and also in cases of phoria
vi. Visual field defects (hemianopias) developing in presbyopes, elderly persons, and poorly
Kerala Journal of Ophthalmology / Volume 29 / Issue 2 / May‑August 2017 81
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Antony: Prisms in clinical practice
Figure 13: Base‑out prism for divergence insufficiency
Figure 14: Prisms treatment for nystagmus
Figure 15: Left homonymous hemianopsia. Hemianopic spectacle
Figure 16: Prism for bedridden patient
Figure 17: Prism treatment for left lateral rectus palsy
motivated patients, prism treatment is undertaken. Prism
trial is performed using prisms in trial set, and appropriate
power can be prescribed. Prisms with their base against the
direction of deviation (relieving prism), are given [Figure 11]. Figure 18: Prism for myasthenia gravis
Following guidelines will help in the proper prism • Prism up to 6 Δ can be given in one eye and half of it in
prescription: the other eye
• Prisms with their base opposite to deviation are given. BI • If the prism power required is high, the total power can
prism are given to correct exodeviations, base‑out prism be divided between two eyes
for esodeviations, base‑up prism for hypodeviations, and • Prisms can be given as glass prisms or Fresnel prisms in
base‑down prisms for hyperdeviations spectacles.
• The range of prism powers prescribed in the treatment
of phoria is usually from 0.5 Δ to 10 Δ. For example: In PRISM THERAPY IN TROPIAS
exodeviation of 10 Δ, 5 Δ BI prism in the right eye (RE)
and 5 Δ BI in the left eye (LE) are given • Prisms are used less commonly in the treatment of
• Both vertical and horizontal prisms can be prescribed tropias than phorias and only in cases where deviation
• A vertical prismatic correction of 10 Δ is the maximum is more than 20° and does not get corrected with other
that can be tolerated. For example: In a vertical methods, and also as an alternative to surgical correction
deviation of 10 Δ (right hyper deviation), 5 Δ base‑down for cosmetic improvement. Principles of prescription are
in RE and 5 Δ base‑up prism in LE are preferred as the same those for phorias
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Antony: Prisms in clinical practice
Figure 19: Prism treatment for ankylosing spondylitis
Figure 20: Prism ballast for contact lens stabilization
Figure 21: Comparison of Conventional Prism and Fresnel Prism
• Prism adaptation – prisms are also given in spectacles,
1 month before surgery to obtain presurgical fusion
of images thereby improving the outcome of surgery.
By knowing how much prism will make the eyes work
together, we can judge how much surgical adjustments Figure 22: Fresnel prism
of eye muscle is necessary.
abnormal head turn and chin elevation in congenital
CONVERGENCE INSUFFICIENCY nystagmus. Prisms with their base kept opposite to null
zone, where the amplitude or magnitude of nystagmus
Prisms are used both in measurements of convergence is minimum (preferred direction of gaze), allow the eyes
(base‑out prisms) and for treatment (BI prism) of convergence
to rotate into position without large head turn. Prisms
insufficiency;[1] when the condition is not getting relieved
with base opposite to the preferred direction of gaze
by correcting the causes, refractive errors, and also by
are given.
orthoptic exercises, BI prisms are prescribed for near work.
Smaller powers below 5 Δ can be attained by decentering
For example: In a case of nystagmus, if nystagmus is
lenses also.
minimum in the right gaze (RE‑abducted and left‑adducted
DIVERGENCE INSUFFICIENCY position – null zone), eyes are in dextroversion and patient
turns face toward left (face turn) to find the null point of
When divergence insufficiency is benign (without any nystagmus.
neurological signs), it can be treated with base‑out prisms
in spectacles or Fresnel prisms. If we can give BI prism in RE and base‑out prism in LE (apex
of both prism directed to right) will shift the image to the
PRISMS TREATMENT FOR NYSTAGMUS right or null zone, and this can enable the patient to keep
face straight without turning face to the left.
Base‑out prisms can stimulate fusional convergence
which will increase the amplitude of nystagmus, resulting Compensatory chin elevation caused by null zone in dorsum
in improvement in the visual acuity. Prisms also correct version can be corrected by base‑up prism.
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Antony: Prisms in clinical practice
also used to stimulate the unaffected antagonistic muscle of
paretic muscle thereby preventing its secondary contracture.
In myasthenia gravis, multiple sclerosis, and Graves’ disease,
variable diplopia can be corrected using prisms. They are
applied at an oblique angle to correct horizontal and vertical
diplopia.[3] Prism requirements vary with disease progression.
Ankylosing spondylitis and other postural deformities with
limited head movement, prism applied base up to spectacle
can change the image angle [Figure 19].
Figure 23: Fresnel prism being applied to surface of spectacle
PRISMS IN CONTACT LENS CORRECTION
PRISMS IN TREATMENT OF HEMIANOPIAS
In CL practice, prisms are used to stabilize the near vision
Patients with hemianopias especially homonymous hemianopia portion of a segmental bifocal CL and to stabilize a toric CL,
and vision in the only one eye can be helped by giving prism using prism ballast [Figure 20].
with its base oriented toward the blind area. This will push
the eye to the seeing area providing a large view of field which FRESNEL PRISM
was normally occupying the blind area. Prism covers only that
portion of spectacle corresponding the blind area. Hemianopic Fresnel prisms are now used more in prism practice as
spectacles, incorporated with prism of about 8 Δ, with its base they are very thin, have only negligible weight, and more
directed to the blind side will serve the purpose. In a patient cosmetically acceptable even in high powers (30 Δ ) than
with only seeing LE and left homonymous hemianopia can be conventional prisms.[4] They are made of polyvinyl chloride
provided with a base‑out prism to see object on his left field. [Figures 21-23].
Prism covers the temporal portion of the left lens.
Fresnel prisms consist of thin narrow prisms arranged in a
PRISMS IN GLAUCOMA AND RETINITIS PIGMENTOSA plastic sheet. Continuous surface of a conventional prism
is replaced by a series of steps. Their design is based on
Advanced glaucoma and RP patients with tubular vision have the principle that power of prism depend on the prism
to restrict the eye movement to a limited range. Prisms help angle and not on its thickness (Augestin Fresnel). Hence, the
to displace peripheral blind area of visual field toward the thickness is reduced to 1 mm. They are available in powers
straight ahead position to the seeing area of visual field. from 1 Δ to 40 Δ. Since Fresnel prism is thin and flexible,
Small segment of Fresnel prism 5 mm from the center of it can be cut into pieces and applied to the back surface
pupil with its BI the same direction of restricted visual field of spectacle. They are preferred in most of the clinical
will help the patient. conditions managed with prisms, especially in the treatment
of squint and to relieve sudden onsight symptomatic diplopia
PRISMS AS AN AID TO THE BEDRIDDEN PATIENT resulting from trochlear and abducens nerve palsies,
thyroid‑related orbitopathy, postcataract surgery diplopia,
Bedridden patients are forced to read or watch television and trauma‑induced diplopia.[5]
in extreme downgaze. If they are provided with 15–30 Δ,
base‑down prism in the form of recumbent spectacle will Declaration of patient consent
allow the patient to read comfortably. Prisms in Fresnel form The authors certify that they have obtained all appropriate
are given temporarily till the patients recover.[2] patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
PRISMS IN INCOMITANT STRABISMUS clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
In paralytic strabismus, prisms are used to deplete diplopia and due efforts will be made to conceal their identity, but
by directing the extra image into suppression area or into anonymity cannot be guaranteed.
retinal periphery where it can be easily ignored. Complete
occlusion or segmental occlusion in one position of gaze in Financial support and sponsorship
single or bifocal form of 10 Δ to 20 Δ is given. Prisms are Nil.
84 Kerala Journal of Ophthalmology / Volume 29 / Issue 2 / May‑August 2017
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Antony: Prisms in clinical practice
Conflicts of interest Binocul Vis Strabismus Q 2002;17:135‑42.
2. 3M Press-on optics-distributed by Peral optics, 30th cross, 4th block, Jay
There are no conflicts of interest. Nagar, Bangalore 560011.
3. Roodhooft J, Van Rens G. A prism is a useful tool in the treatment of
REFERENCES vertical diplopia. Bull Soc Belge Ophtalmol. 1998;268:215‑22.
4. Flanders M, Sarkis N. Fresnel membrane prisms: Clinical experience.
Can J Ophthalmol 1999;34:335‑40.
1. Stavis M, Murray M, Jenkins P, Wood R, Brenham B, Jass J. Objective 5. Wylie J, Henderson M, Doyle M, Hickey‑Dwyer M. Persistent binocular
improvement from base‑in prisms for reading discomfort associated diplopia following cataract surgery: Aetiology and management.
with mini‑convergence insufficiency type exophoria in school children. Eye (Lond) 1994;8(Pt 5):543‑6.
Kerala Journal of Ophthalmology / Volume 29 / Issue 2 / May‑August 2017 85
