Binocular vision problems OEP ii.

Alternating cover test

Binocular vision anomalies 1. Determine direction & magnitude
a. Occur: problem w coordinated use of of phoria (observe uncovered eye)
eyes a. IN → EXO → BI
b. Classification according to comitancy b. OUT → ESO → BO
i. Comitant c. UP → HYPO → BD
ii. Incomitant: deviation varies in d. DOWN → HYPER → BU
different positions of gaze f. Reasons for intervening when a
depending on w/c eye is fixating binocular vision anomaly is present
c. Classification i. If anomaly is causing symptoms or
i. Heterophoria decreased visual function
1. Decompensated → strabismus ii. If anomaly is likely to worsen if left
2. compensated untreated
ii. Strabismus: heterotropia or squint; iii. If anomaly is likely to be an ocular
visual axes are deviated: one LOS or systemic pathology
not fall on object of regard g. A heterophoria can become
1. Constant decompensated due to opacity in media
2. intermittent or illness then cause symptoms like
d. Should px wear rx? Yes. Check through diplopia and headaches which leads to
orthoptic tests. strabismus and/or amblyopia →
e. Examine suppression
i. Cover test h. Treatment/management
1. Line above worst eye’s VA i. Eye exercises
2. Cover part: diff b/w tropia & phoria ii. Prisms
3. Uncover part: diff b/w alternating & iii. Patching (occlusion) or penalization
unilateral iv. Surgery
a. Alternating tropia: either OD or
OS aligned w target
b. Unilateral: only fixates w
troping eye when fixating eye
occluded
4. Results
a. OS no move when OD
uncovered
i. Alternating tropia
b. OS moves when OD
uncovered
i. Constant left tropia
c. OD no move when OS
uncovered
i. Alternating tropia
d. OD moves when OS
uncovered Heterophoria
i. Constant right tropia
a. Symptoms: check if heterophoria is i. Both lines straight horizontal
decompensating bc will develop sensory = normal
adaptation like ARC ii. Line on right at the bottom =
correct with BD
iii. Line on right at upper =
correct with BU
d. Manage only decompensated
heterophoria
i. Remove cause of decompensation
1. Dim light = poor sensory fusion
b.
then inc light
i. Young children or uncooperative
ii. Eye exercises
older pxs: may need objective
1. Fx-ive in small to moderate
testing to check if decompensating
exphoria
c. Examine
2. Purpose: inc fusional reserve that
i. Alternating cover test w prisms to
opposes heterophoria
determine if large or small phoria
a. Ex: inc convergent fusional
ii. Mallet fixation disparity (@D & N)
reserves in exophoria
1. Evaluate fixation disparity
3. Three cats exercise
2. Detect suppression
3. Procedure
a. Horizontal
i. OD sees upper line at right
side
ii. OS sees lower line at left
a.
side
b. Vertical
i. OD sees line at right side
ii. OS sees line at left side

c. b.
d. Results iii. Refractive modification
i. See two lines, otherwise 1. Some cases: decompensation is
suppression caused by uncorrected refractive
ii. Horizontal: upper line top of error
bottom (one straight line) = a. Ex: uncorrected hyperopia in
no FD esophoria OR uncx myopia in
iii. Upper line to left of lower line exophoria or astigmatism
= crossed FD = EXO = BI impairing sensory fusion
iv. If on right: uncrossed = ESO b. Sometimes, already adequate cx
= BO but still need refractive
e. Vertical modification
 i. Use: convergence excess i. Eso greater at distance. If
esophoria: eso worse at significant: do cycloplegic
near. Use: BF cx refraction)
c. Negative add: (minus lenses to ii. Rule out possibility of lateral rectus
emmetrope) to induce palsy
accommodative convergence to iii. Manage:
overcome exophoria 1. Eye exercise to increase
i. “Exercise glasses” & goal is divergent fusional reserves at
to reduce “add” distance
ii. Only done to those w a. Push-up method
adequate accommodation c. Convergence excess (near esophoria)
d. Mallet: add till strips aligned i. Rule out latent hyperopia
i. Increase minus for exophoria ii. Manage:
ii. Increase plus for esophoria 1. Multifocals
iv. Prismatic correction 2. Prismatic cx (mallet’s fixation
1. Common for cx in older pxs, BI disparity)
prism in reading glasses 3. Surgery
2. Small vertical heterophoria: best d. Convergence insufficiency
for prisms i. Near convergence closer than 8 to
3. Add prisms according to results 10 cm
until straight line ii. Sometimes associated with
v. Surgery convergence weakness exophoria
1. Rarely required for iii. Manage:
decompensated heterophoria. 1. Eye exercise: push-up & bead on
Only when heterophoria is v large string
w considerable symptoms a. In older pxs: stress that only
Specific types of heterophoria single image not clear
a. Mixed or basic esophoria
i. Esophoria is similar at distance &
near (if decompensated then treat
at both distances, add plus)
ii. Can decompensate when ill
iii. Manage:
1. If decompensating but not at a
specific distance and not fully
accommodative (not fully cx by
maximum plus revealed by
cycloplegic)
2. Maximum plus
3. Eye exercise
4. Prisms Strabismus
5. Surgery
b. Divergence weakness (distance
esophoria)
 i. Test for HARC or global
suppression
ii. Polarized over rx at distance
& increase light (counteract
light-absorbing effect of
polarized filters).
iii. Results
- If see 2 targets: NRC
a. Sensory adaptation to strabismus - If see only one green
i. Strabismic amblyopia is a sensory strip: global suppression
consequence of strabismus - If both green strips but
ii. To avoid diplopia, younger pxs only one OXO then
either: suppress strabismic eye or HARC
develop HARC
1. HARC = form of
pseudo-correspondence
2. Two small suppression areas in
strab eye VF:
a. One at fovea and one at zero
point (strabismic eye VF that
neo-corresponds w fovea of
non-strab eye)
b. ^ needed bc AC would be
iv. Check motor status by doing
difficult
cover test to ensure px did
b. Examine
not change fixation
i. Motor:
c. When do you need to do something
1. determine size of deviation using
i. If strabismus causing symptoms or
cover test
decreased visual function
2. Estimate degree of deviation by
1. Large angle strabismus: surgery
maddox wing or maddox rod
2. Small angle (cosmetically good) w
ii. Sensory
good sensory adaptation: leave
1. The innate normal correspondence
alone (if treat, may lead to
is under the ARC so if the tests try
intractable diplopia)
and fix the NC then diplopia will
a. Can do eye exercises
occur
b. If cannot = do prismatic or
2. Inappropriate for determining
refractive approach (safest,
sensory status (bc artificial,
check which power where
naturalistic will yield the accurate
diplopia is not present)
results): synoptophore.
3. Best tests: bagolini & mallet
modified OXO test

ii. If situation is worse when left

a. Modified Mallet large OXO test
untreated
 1. Intermittent strabismus w/c can a. Small angle strabismus, less than 6
sometimes lead to constant prisms
strabismus b. Microtropia w identity = angle of EF
a. Ex: hyperopic w esophoria same as angle of strabismus
becoming esotropia, correct c. How to diagnose microtropia
hyperopia if that is the cause

d. How to investigate
i. No strabismus seen on cover testing
ii. 4 BO test
1. In microtropia, likely to have a
central suppression area. If put 4
prim BO then no movement bc
target displaced in central
suppression area
2. If no strabismus
a. Both eyes make a saccadic
version movement then eye
w/o prism will move
b. Eye w prism will move w other
eye maintain fixation
3. If microtropia
a. IF prism in front of strabismic:
No movement of either eye
b. IF prism in front of
non-strabismic: both eyes will
move but no corrective
movement
4. Occlude normal eye then repeat
test w other eye. If fails to move
then suggests central scotoma
e. What to do: no treatment (rare to find
microtropia w symptoms)

Microtropia Amblyopia
a. Visual loss from impairment or
disturbance to the normal development
of vision. Early interruption to
development of vision causing visual
deficit w/c cant be corrected refractively.
b. Sensitive period, until 7 - 8 y/o: visual
system capable of developing amblyopia
i. Any interruption to binocularity or
clear image = amblyopia

f. Rule out reduced vision from pathology

c. Classifications
i. Amblyopia is detected as reduced
i. Organic: from pathological
vision in one eye
abnormality like retinal disease or
ii. Negative sign: exclude pathology
toxic factors
and check fundus
ii. Functional: “lazy eye”
iii. Positive sign: look for amblyogenic
1. Isometropic: both eyes have an
factors (table above)
amblyogenic refractive error
2. Hysterical: reduced vision in
one eye w/o cause but due to
psychological factors
d. How to diagnose amblyopia
i. Difference b/w best corrected
acuity of two eyes of two lines or
more and/or acuity of amblyopic
eye is less than 20/30.
e. How to check or diagnose amblyopia
i. Detect strabismic amblyopia by
using crowded targets bc the VA is
much worse than isolated.
a. Ex: Lea symbols test
 i. There is no sensitive period for this
to be treated, attempt at any age
but most effective in adults
ii. Treat
1. Prescribe full refractive cx
(cyclo)
a. Follow-up in 4 to 6 weeks then
if one line or more
improvement, continue w
correction till stops improving
or acuity is equal
2. If stops improving then occlude
w full refractive correction
a. NOT BE FULL-TIME
b. 4-6 hours a day
g. Strabismic amblyopia c. Follow-up in 4-6 weeks
i. Most effective if treatment is given Incomitant deviations
before 7-12 y/o (bc binocular a. Angle varies in different positions of
sensory adaptations to strabismus: gaze depending on which eye is fixing
HARC or global suppression) b. Congenital or acquired
ii. Under 3 y/o (risk: occlusion c. Can be stable then decompensate
amblyopia) d. Classifications
1. Occlude good eye for one day i. Neurogenic: caused by lesion
per year of age affecting neurosystem
2. Make sure appropriate 1. Eye will deviate opposite to the
refractive correction for action of the palsied muscle
amblyopic eye 2.
3. Follow up 3 weeks later ii. Mechanical: muscular or orbital lesion
iii. 3-7 y/o mechanically restricts globe
1. Occlude good eye or blurred to movement
an acuity worse than amblyopic
eye
iv. 7-12 y/o
1. Treatment may lead to HARC or
global suppression
2. Refer to surgeon

Mmnemonics: SIRADD SOINN

Superior & inferior recti: adduct
Superior recti & obliques: intort

h. Anisometropic amblyopia
e. How to investigate
i. Ocular motility test

ii. Procedure
1. Penlight 50 cm from patient
2. Move in the directions of gaze
3. Check upgaze and the downgaze
4. Occlude OS then repeat and then
OD
f. When do I need to do something
i. Refer to: detect underlying pathology
 c. NOTE: Direction of nystagmus
reverses when cover is moved from
one eye to another
d. Acquired (neurological) nystagmus:
occur at any time, after first few months
of life
i. Cause: lesion or trauma affecting
motor pathways
e. Two eye movement anomalies
i. Ocular flutter: burst of horizontal
saccades which can occur in
healthy infants or pathology
ii. Spans nutans: occurs in 1st year
of life w nodding and abnormal
head posture (benign but also can
be associated w pathology)

f. When do i need to do something?

None but if recent onset or changing
then refer to ophthalmologist

Nystagmus
a. Early onset nystagmus: first six months
of life
i. May occur secondary to a sensory
visual defect or idiopathic (defect
in motor control of eye move)
b. Latent: usually ass w infantile esotropia
syndrome (occurs early, 1st year of life)
i. Latent latent nystagmus: marked w
one eye covered
ii. Manifest latent nystagmus:
worsens on occlusion
Accommodative anomalies

Non-strabismic BV Anomalies
Convergence insufficiency
a. Symptoms
i. Diplopia at near
ii. HA above eyes, later in the day (ass
w near tasks)
iii. BOV near, words moving
iv. Relief: close one eye
b. Signs
i. Receded NPC greater than 6 cm
1. Diplopia when repeat w red lens
ii. Near exophoria > 6-8 PD
1. Intermittent XT during near test
iii. Near lateral phoria test: higher
exophoria
iv. LOW
1. AC/A
2. Accommodative facility (diff
clearing OU)
3. NRA or PRA
 a. Normal: NRA: +2.50 & PRA: Divergence Insufficiency
-3.50 a. Symptoms
c. Management i. Intermittent diplopia
i. Eye exercises: b. Signs
1. pencil push-up: 5 minutes daily i. 16 PD at distance, less at near
for 2 weeks ii. Esodeviation is concomitant (usually
2. Bead on string: for NPC > 20 cm alternating)
or more iii. LOW AC/A
ii. Refractive correction: plus lens iv. LOW negative fusional vergence
1. Plus lens: b/w +0.75 to +1.25 D, c. Management
repeat of abnormal binocular i. Prism: maximum amt is 5 - 6 BO
tests w lens (NPC, NRA/PRA, (perform prism adaptation test)
MEM) ii. Vision therapy: push-up or brock
2. Ff up after 2 months string
iii. Visual hygiene Exodeviations
Divergence excess
a. Is: intermittent CT whose angle of
Convergence excess: can lead to esotropia deviation is 10 to 15 PD greater than
a. Symptoms near
i. Diplopia w eyestrain b. Symptoms: photophobia
ii. HA above eyes late in the day c. Signs:
iii. BOV at d or n i. When deviation present: NRC w
b. Signs suppression or ARC
i. Esophoria greater at near than ii. XT with V pattern may be present
distance d. Management
ii. HIGH i. Vision therapy: Brock string
1. AC/A ii. Botox: kids b/w 2 & 4. Angle cx up to
2. NPC 10 PD
iii. High NRA & LOW PRA (less than iii. Minus lenses
1.25) Thyroid related ophthalmopathy
iv. Low divergence ranges BI & high a. Aka: graves
convergence BO at far b. AID causing expansion of orbital tissues
v. Accommodative facility: diff clearing = orbital congestion, ass w
minus lenses OU hyperthyroidism
c. Management c. Symptoms:
i. Plus lenses at near: +0.75 to 1.25 D i. FB sensation
(unless hyperope then higher) ii. Diplopia w photophobia
ii. Visual hygiene iii. Lacrimation
iii. Exercise: pencil push-up iv. Retro Orbital discomfort (during eye
movements)
d. Signs:
i. Lid swelling & proptosis
ii. Lid & periorbital edema: worse in am
e. Do MRI or CT scan and thyroid function
screening to eliminate other ddx
f. Treatment: refer (prism to relieve
diplopia)