4. BV IV - Management Flashcards
What is a good way of helping px determine their ideal working distance? (Harmon working distance)
Put fist on chin, where the elbow is, is where the ideal working distance should be.
What are the 5 common sense advice that can be given to px with accommodative vergence problems?
- Encourage a balanced lifestyle
- Limited the amount of near tasks or visually demanding tasks (15-30mins)
- Pace amount of near work required over time (not all at once)
- Adopt a Harmon working distance - elbow to chin
- Counsel on ideal lighting and environment
US national guidelines for management accommodative vergence dysfunction in non-strabismics:
* Assist px to function efficiently in ...
* To relieve ..., ... and ... symptoms associated with these disorders
* Guideline list specific dysfunction with ... and ... recommended for each condition
* Guidelines are review ...
US national guidelines for management accommodative vergence dysfunction in non-strabismics:
* Assist px to function efficiently in school performance, at work and/ or in athletic activities
* To relieve ocular, physical and psychological symptoms associated with these disorders
* Guideline list specific dysfunction with ideal treatment plan and duration of therapy recommended for each condition
* Guidelines are review biannually
What are the managing principles of accommodative vergence issues?
- Why does your px have this condition. What are their risk factors?
- What is the goal of treatment? How do you communicate this with them?
- Does treatment help their symptoms? How will the diagnosis affect the px personally?
- Discuss the consequences of no treatment in their individual cases
Sequential management plan for accommodative vergence problems:
1. Manage any clinically significant ...
2. Counsel px if ... is a risk factor and can be ...
3. Manage any accommodative problems first where possible using ...
4. Consider ... options where appropriate, if px is a good canditate and ...
5. Consider compensatory options such as ... or ... if other options are not suitable
Sequential management plan for accommodative vergence problems:
1. Manage any clinically significant refractive error
2. Counsel px if near workload is a risk factor and can be modified
3. Manage any accommodative problems first where possible using lens addition
4. Consider vision therapy options where appropriate, if px is a good canditate and motivated
5. Consider compensatory options such as compensatory prisms or lens additions if other options are not suitable
Near plus addition helps with .... Near add prescribed should be determined according to px’s ..., magnitude of ... and .... The larger the lag, ...;
For esophoric px, the ... amount needed to make px ... (...pd at near) should be prescribed;
Px with steep AC/A means that ... will be sufficient.
Addition typically ranges from ... to .... Anything higher should not be prescribed for this purpose as ... will interfere with ... in ....
Near plus addition helps with fatigue associated with near work. Near add prescribed should be determined according to px’s accommodative lag, magnitude of esophora and AC/A ratio. The larger the lag, the higher plus;
For esophoric px, the minimum amount of plus needed to make px OrthoP (1-6pd at near) should be prescribed;
Px with steep AC/A means that a small plus will be sufficient.
Addition typically ranges from +0.75 to +1.50. Anything higher should not be prescribed for this purpose as >+1.50 will interfere with working distance in non-presbyopes.
Determine the near add required for this px with convergence excess:
* 7 Δ Eso @near
* AC/A 4Δ/D in plus direction
+1DS add will give 4Δ Exo shift,
∴ Px’s Eso will drop to 3Δ
* +1.50DS add will give 6Δ Exo shift
∴ Px’s Eso will drop to 1Δ = Ortho
Determine the near add required for this px with accommdative insufficiency:
* MEM Ret +1.50 DS
2 options:
* +1.00DS should get lag back to +0.50
* Minimum option is to go with +0.75DS, which may already be sufficient to support accommodation and reduce symptoms
Yoked prism is the last resort option or used as ... specific for ... related deviation, such as ... and .... Equal prisms are placed in each eye in ... and they shift the image towards the ..., tricking the visual system ...
No more than 2Δ ... for Exo deviations → shifts image down and ...
No more than 2Δ ... for Eso deviations → shifts image up and ...
Yoked prism is the last resort option or used as an adjunct to other treatments specific for distance related deviation, such as divergence insufficiency and basic esophoria. Equal prisms are placed in each eye in the same direction and they shift the image towards the apex, tricking the visual system spatially
No more than 2Δ BU for Exo deviations → shifts image down and closer
No more than 2Δ BD for Eso deviations → shifts image up and further away
Giving a minus addition at ... is a treatment option for ... or ... at .... This is based on stimulating ... to drive .... There are no clear guidelines, but there are research by PEDIG (...) with supporting evidence. Around ...DS addition is recommended at distance in ... and ... to stimulate ... and therefore ... to restore and improve .... Px may also require ... at near to counter the distance addition.
Giving a minus addition at distance is a treatment option for divergence excess or basic exophoria at distance. This is based on stimulating accommodation to drive convergence. There are no clear guidelines, but there are research by PEDIG (paediatric eye disease investigation group) with supporting evidence. Around -2.00DS addition is recommended at distance in basic Exo and divergence excess to stimulate accommodation and therefore accommodation convergence to restore and improve alignment control. Px may also require near plus add at near to counter the distance addition
Compensatory prisms are only useful in ... and are used when all else fails. This should not be used in ..., due to .... A ... amount should be prescribed for the desired shift or ... that eliminates .... This prism will bring the image to where the eyes are ....
BI shifts image ... to ... eye
BO shifts image ... to ... eye.
Most commonly used magnitude of ... combined with ... to determine minimal prism required to ...
Compensatory prisms are only useful in adults and are used when all else fails. This should not be used in kids, due to risk of prism adaptation. A minimal amount should be prescribed for the desired shift or change in vergence that eliminates diplopia. This prism will bring the image to where the eyes are deviated.
BI shifts image outwards to exodeviated eye
BO shifts image inwards to esodeviated eye
Most commonly used magnitude of heterophoria/tropia combined with vergence or vertical fusional reserves to determine minimal prism required to relieve symptoms or to relief diplopia
Compensatory Prisms for each deviation:
* Exo = ...
* Eso = ...
* R hyper = ... ...
* L hyper = ... ...
* R hypo = ... ...
* L hypo = ... ...
Compensatory Prisms for each deviation:
* Exo = BI equal split
* Eso = BO equal split
* R hyper = BDR BUL
* L hyper = BDL BUR
* R hypo = BUR BDL
* L hypo = BUL BDR
The goal of vision therapy is to ... under any stimulus condition.
1. Monocular - ..., ... skills → flippers
2. Bi-ocular - transition from ... to ..., anti-...-simultaneous viewing → loose prisms, red green bars
3. Binocular - ... and ... in a ... environment → loose prisms + ..., ..., HTS computer based therapy
4. Proficiency - ... and adding distractions
The goal of vision therapy is to re-establish automated, effortless accommodative and vergence responses under any stimulus condition.
1. Monocular - accommodation, fixation skills → flippers
2. Bi-ocular - transition from monocular to binocular, anti-suppression-simultaneous viewing → loose prisms, red green bars
3. Binocular - vergence and accommodation in a binocular environment → loose prisms + flippers, brock string, HTS computer based therapy
4. Proficiency - combining skills and adding distractions
Convergence insufficiency is one of the most .... This is one of the most common causes of .... Characteristic features of CI includes:
* ... > ...
* Abnormal ...
* Reduced ... vergence skills
* Reduced ...
Convergence insufficiency is one of the most commonly presenting visual efficiency disorders. This is one of the most common causes of near visual asthenopic symptoms. Characteristic features of CI includes:
* Near Exo > Distance Exo
* Abnormal NPC
* Reduced BO vergence skills
* Reduced PRC
Treatment Protocol for Convergence Insufficiency
* Correct any significant ...
* Educate & counsel px on ways to ... and avoid ... their visual system
* ... addition
* Vision therapy (in office or computer based home therapy) to develop ... and develop better ... and ...‘
* ... prism to compensate for ... at ...
* Referral if .../ .../ ...
Treatment Protocol for Convergence Insufficiency
* Correct any significant refractive error
* Educate & counsel px on ways to reduce risk of near visual stress and avoid overloading their visual system
* Plus near addition
* Vision therapy (in office or computer based home therapy) to develop more efficient voluntary control of convergence and develop better reserves and facility‘
* BI prism to compensate for exo at near
* Referral if sudden onset/ recent illness/ trauma suspected
