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Binocular vision 2 > Investigation and management of anomalies of convergence and accommodation > Flashcards

Investigation and management of anomalies of convergence and accommodation Flashcards

1
Q

list the 4 classifications of convergence anomalies

A
  • Convergence insufficiency
  • Convergence fatigue
  • Convergence paralysis
  • Convergence accommodative / spasm
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2
Q

what is a convergence insufficiency

A

inability to obtain adequate binocular convergence without undue effort

can’t converge the eyes binocularly but can converge eventually but with a lot of effort

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3
Q

what is convergence fatigue

A

inability to maintain convergence over time

can converge the eyes binocularly to begin with but over time this fatigues and you can do it

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4
Q

which classification of convergence anomaly is relatively common

A

convergence insufficiency

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5
Q

what are the 2 types of convergence insufficiency

A
  • primary
    or
  • secondary
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6
Q

convergence insufficiency is easily….

A

treatable

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7
Q

what is meant by a primary convergence insufficiency

A

the first ocular thing that happens is the convergence insufficiency

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8
Q

what is meant my secondary convergence insufficiency

A

something else happened before the CI. which then caused the CI

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9
Q

list 8 precipitating factors of a primary convergence insufficiency

A
  • Illness
  • Fatigue
  • Drugs: Antidepressants/Cocaine
  • Pregnancy
  • Students with a lot of exam stress
  • Change of jobs/lifestyle
  • Computers
  • Constant distance vision
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10
Q

list 7 things that a secondary convergence insufficiency can be due to

A
  • Heterophoria - uncorrected exophoria
  • Uncorrected refractive errors
  • Accommodative insufficiency
  • Iatrogenic weakened medial recti
  • Parkinson’s
  • Thyroid eye disease
  • Inter nuclear ophthalmoplegia
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11
Q

what do you need to do in order to find out if a convergence insufficiency is primary or secondary

A

you need to conduct a good BV exam

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12
Q

list 7 symptoms of convergence insufficiency and fatigue (i.e. when trying to converge but can’t)

A
  • Headaches
  • Eyestrain
  • Difficulty changing focus
  • Asthenopia
  • Blurred vision (XOP decomp.) - if dipl is very close together
  • Diplopia (XOT) - if fail to converge
  • Convergence fatigue - symptoms occur after prolonged near work (so no symptoms initially)
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13
Q

when do the symptoms of convergence fatigue occur

A

after prolonged near work

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14
Q

list all 11 tests that can be conducted to investigate a convergence insufficiency and fatigue

A
  • cover test
  • convergence, near point with RAF rule
  • jump convergence
  • prism fusion range
  • accommodation

others that can be done:

  • Measure deviation with prism cover test
  • Visual acuity
  • Stereoacuity
  • Ocular motility
  • Fundus examination
  • Cycloplegic refraction in children
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15
Q

what can a cover test reveal about a convergence insufficiency

A
  • XOP /XOT at near

- Orthophoria distance - as eyes don’t need to converge

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16
Q

what can a cover test reveal about a convergence fatigue

A

XOP /XOT at near after prolonged dissociation

so no problems initially

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17
Q

what will a convergence near point test with a RAF rule reveal about a convergence insufficiency and what is the advantage of using a RAF rule

A

will have a reduced or poorly maintained near point

this is done to get a precise measurement

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18
Q

why is it good practice to measure near point with the RAF rule 3 times

A
  • to get a precise measurement for CI

- for CF it will be revealed on the 2nd or 3rd time and not the 1st (which will show as normal)

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19
Q

what will a convergence near point test with a RAF rule reveal about a convergence fatigue

A

on 2nd/3rd attempt NP reduces

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20
Q

which 2 ways can you test convergence near point with the RAF rule

A
  • subjectively
    and/or
  • objectively
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21
Q

how is convergence near point with the RAF rule tested subjectively, and what do you need to keep in mind

A
  • When patient reports diplopia

- Remember that the target will be blurred (test does NOT examine accommodation)

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22
Q

how is convergence near point with the RAF rule tested objectively and give an example of how the results will be written down for a convergence fatigue

A
  • Watch the patients eyes for convergence to break:
    Note the eye which diverges first
    Note the distance and whether they were able to maintain convergence
    Note whether diplopia was noticed

Conv: binoc to 10,15,20 cms re diverged with diplopia

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23
Q

describe how a jump convergence is carried out when testing for convergence insufficiency or fatigue and what the results will be like for someone with a convergence insufficiency

A
  • Hold two objects in front of the patient (ask px to look at further away object)
  • One object held closer to their face than the other
  • Request the patient to look from the distance object to the near object each time bringing the near object closer
  • Reduced in CI
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24
Q

which other convergence test is jump test harder to do than

A

near point with RAF

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25
Q

in which type of patients in particular is prism fusion range carried out in and why when measuring convergence insufficiency

A
  • children
  • as they can make answers up
  • a child is able to make their eye drift out when measuring with the RAF rule
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26
Q

what will the results in a prism fusion range test show in a child with convergence insufficiency

A

Base Out (cOnvergence) at near = reduced in CI

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27
Q

what will the results in a prism fusion range test show in a child with convergence fatigue

A

base out at near reduces on prolonged testing

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28
Q

why is accommodation tested when investigating convergence insufficiency/fatigue

A

because it is part of the near triad:

  • convergence
  • accommodation
  • pupil miosis

so they’re all inter-linked as with a CI you also get a accommodative insufficiency with it.
so if a px has a convergence problem, always check accommodation with it

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29
Q

describe how accommodation is measured when investigating convergence insufficiency

A
  • Near point assessed with RAF rule in dioptres
  • Assessed three times (insufficiency versus fatigue)
  • Need to know normal level for their age
  • Assessed monocularly and binocularly (differential diagnosis CI or AI)
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30
Q

how can you tell that a px has a problem with convergence and not accommodation when measuring accommodation with the RAF rule

A
  • Assessed monocularly and binocularly
  • if binocular accommodation is reduced, but when you check monocularly and accommodation is perfectly normal for their age, then this is a convergence problem
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31
Q

what is the outcome/results of measuring the deviation with a prism cover test with a CI patient

A
  • XOP/XOT usually at near
  • Orthophoria at distance

if the exophoria is getting bigger and bigger = convergence insufficiency is getting worse

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32
Q

what is a reduced visual acuity associated with, when investigating convergence insufficiency

A
  • Reduced if associated with AI
  • measured at distance and near
  • if reduced at near = accommodation problem
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33
Q

what is the outcome/results of measuring stereo acuity on a CI patient

A
  • Might be reduced or absent

- if CI gets worse and exophoria becomes exotropia = steer acuity can get worse

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34
Q

what is the outcome/results of measuring ocular motility on a CI patient

A
  • If incomitant refer (TED, INO)
  • as a secondary CI can be caused by thread eye disease or INO, so make sure nothing else is the cause apart from the CI itself
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35
Q

what are the 3 main steps with management of convergence insufficiency

A
  • Treat any pathology
  • Significant refractive error corrected - give glasses
  • Exercises - to most CI px’s
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36
Q

what is the first line of treatment for convergence insufficiency and give 5 examples

A

orthoptic exercises:

  • dot card
  • convergence
  • jump convergence
  • base out fusion range at near
  • voluntary convergence
  • stereogram/positive relative convergence
37
Q

list the steps of how to do an orthoptic exercise using the dot card

A
  • Card length 30 cms.
  • Place the card at the end of the nose
  • The line will appear double (phys dip)
  • Need to keep each dot as single
  • Start with the dot furthest away and come closer whilst keeping the dot single
  • want px to manage to look at the closest dot and keep it single
38
Q

describe how convergence exercise is carried out for a patient with a CI

A
  • Binocular convergence with a pen
  • Using Lollipop stick with letters
  • for a presbyope, the letter will not be clear, but just want them to keep it single
39
Q

how will a patient be able to do base out prism fusion range at near to exercise their CI

A

by us lending them a prism bar

40
Q

describe how the stereogram is carried out as an exercise for CI

A
  • 2 similar pictures with some differing characteristics
  • Patient requested to hold the card at approx. 33cms
  • The patient then stares at a near object (pencil) in front of the card. They must not look at the card itself to begin with
  • The position of the target is then changed until 3 figures are seen

= positive relative convergence

41
Q

list 6 points to take into consideration about orthoptic exercises for CI in general

A
  • Watch each patient carrying out their exercises (to make sure they do it properly)
  • Symptoms may initially worsen e.g. headaches, eye strain
  • Lots of encouragement
  • Specify how much time
  • Must relax eyes afterwards:
    By looking far away or closing eyes
    To reduce risk of convergence spasm
  • Should be regularly monitored
42
Q

give an example of why a person who is doing orthoptic exercises for their CI should be regularly monitored

A

because occasionally, the patient can do so many exercises that their convergence spasms i.e. goes to the opposite way meaning they have an over convergence and an esophoria

43
Q

what other treatment will you do for a CI if occasionally the exercises doesn’t work and name the type of this treatment

A
  • surgery

- Von Noorden (1976) consider M-R resections with large angled deviations (VERY,VERY RARE)

44
Q

how will you go about treating a secondary CI

A

by addressing the primary condition first

45
Q

what is a convergence paralysis

A

The ability to converge closer than infinity is entirely lost
i.e. no convergence what so ever

46
Q

what are the 2 types of convergence paralysis

A
  • primary
    or
  • secondary
47
Q

list 4 possible causes of secondary convergence paralysis and what must you do with these patients

A
  • Closed head injury
  • Viral illness
  • Occlusive vascular disease
  • Encephalitis feature of Parinaud’s

must refer the last 2 patients urgently, always refer someone with a convergence paralysis

48
Q

list the 6 signs and symptoms of convergence paralysis

A
  • At distances closer than infinity:
    Nil convergence
    XOT
    Crossed diplopia
  • Accommodation may be normal reduced or absent at distances closer than infinity
    Blurred near v-a if accommodation effected
  • Pupillary response maybe absent for convergence
    present for light
  • Normal ocular movements
    unless associated with another neurological condition
  • Examined in exactly the same way as CI
  • Absent positive fusion range
    good negative fusion range
49
Q

what type of signs and symptoms will a patient with convergence paralysis have at distances closer than infinity

A

Nil convergence
XOT
Crossed diplopia

50
Q

how will a patients accommodation be and symptoms with convergence paralysis

A

Accommodation may be normal reduced or absent at distances closer than infinity
Blurred near v-a if accommodation effected

51
Q

what will a patient with convergence paralysis pupillary response be like

A

maybe absent for convergence

present for light

52
Q

what will a patient with convergence paralysis ocular movements be like

A

Normal ocular movements

unless associated with another neurological condition

53
Q

what will a patient with convergence paralysis fusion range be like

A

Absent positive fusion range

good negative fusion range

54
Q

list the 6 management steps/options of convergence paralysis

A 
- Urgent referral: dont try to treat yourself  
Underlying cause investigated
Fundus examination (pathology treated accordingly)
  • Occlusion: to stop diplopia, can occlude specs or use occlusive CL
  • Botulinum Toxin (BT)
  • Base in prisms to correct XOT: to also stop diplopia
  • If also has AI then near reading addition: treat with convex lenses
  • Adapt to symptoms
55
Q

what else does a spasm of convergence also cause and what does this make difficult

A
  • spasm of accommodation and miosis

- therefore unable to determine which was the primary cause

56
Q

what happens in the eye as a result of a convergence spasm

A

MR may become contracted

57
Q

what happens in the eye as a result of accommodative spasm

A

Ciliary muscle becomes contracted

58
Q

list 5 possible aetiologies of convergence/accommodative spasm

A
  • Over zealous treatment of CI: too much exercise
  • Uncorrected hypermetropia: try to focus their eyes themselves, in doing that it locks in
  • Intermittent distance XOT
  • Organic:
    Drugs/ Inflammation/ alcohol
    Problem within the brain: lesions caused by strokes or multiple sclerosis, so must treat these px very carefully
  • Non organic:
    Psychological: main cause and mainly in women
59
Q

list 8 signs and symptoms of convergence/accommodative spasm

A
  • Could result in a SOT
    (uncrossed diplopia)
  • SOT >distance and lateral positions of gaze
  • Blurred vision in the distance - accommodative spasm
  • Macropsia - image size is bigger than is naturally is
  • Constricted pupils
  • Pseudomyopia
  • Headache
  • Lead on dynamic retinoscopy
60
Q

explain what pseudo myopia is (caused as a result of convergence/accommodative spasm)

A

when someone is really accommodating a lot, it illustrates a pseudo myopic eye as the rays of light will fall infront of the retina

dry ret and auto refractor will show myopia and then after a cylcoplegic refraction, they can show as hyperopic

61
Q

what is the differential diagnosis of a convergence/accommodative spasm and list 3 signs that differentiate this from a convergence/accommodative spasm

A
  • Sixth nerve palsy:
    Pupils normal
    Dolls head abnormal
    V-A normal

if a px has an esotropia that is greater in the distance, then that could be a 6th nerve palsy

62
Q

explain how a normal dolls head works which is present in a accommodative/convergence spasm but not in a 6th nerve palsy which it is found to be abnormal

A

normal = each eye will fully abduct

63
Q

list 8 things that you can do to manage a convergence/accommodative spasm

A
  • Pathology treated accordingly
  • Cycloplegic or even better atropine refraction to elicit full hypermetropic Rx
  • ANY hypermetropic refractive error corrected
  • Daily atropine instillation (with convex lenses to help near work)
  • Monocular occlusion
  • Botulinum toxin
  • Psychiatric counselling
  • Treatment should include improving their negative fusion amplitude

this spasm can happen in different distributions e.g. a little bit of convergence spasm and a lot of accommodative spasm. so need to manage appropriately to the level of spasm that they got

64
Q

list the 3 classifications/types of accommodative disorders

A
  • Accommodative insufficiency
  • Accommodative paralysis
  • Accommodative inertia
65
Q

list the 5 possible aetiologies of accommodative insufficiency/fatigue

A
  • High hyperopia
  • Children with Down’s syndrome
  • Illness: Infection or glandular fever
  • Drugs: antihypertensive, antidepressants
  • Trauma
66
Q

list the 6 types of symptoms of a accommodative insufficiency and fatigue

A
  • Burred vision at near
  • Remote NP accommodation
  • Asthenopia
  • Micropsia: image is smaller than what is naturally is
  • Associated with CI
  • Occasionally SOP because effort to accommodate, it pulls their eyes in

If accommodative fatigue - then above symptoms occur after prolonged near work

67
Q

list three tests that can be done to investigate accommodative insufficiency/fatigue

A
  • near point of amplitude - subjective
  • dynamic retinoscopy - MEM or Nott method
  • flipper lenses
68
Q

describe how will you investigate someones accommodative insufficiency/fatigue from their near point of amplitude

A
  • Using RAF rule with small print
  • Carry out monocularly and binocularly
  • Adjust for age
69
Q

describe how will assess someones accommodative insufficiency/fatigue with flipper lenses

A
  • pairs of plus and minus lenses
    +/-1.00
    +/-1.50
    +/-2.00
  • View a near target through plus lenses
  • When vision clears flip to the minus lenses
  • Count how many cycles you can clear in a minute
  • 1 cycle is one rotation from plus to minus to plus again

10 cycles of +/-2.00 is normal for a young adult
Like amplitude varies with age

70
Q

what is regarded as normal accommodative facility for a young adult

A

10 cycles of +/-2.00

71
Q

list 4 signs of accommodative insufficiency, revealed from the various tests used to assess it

A
  • XOP or SOP at near (because of effort to accommodate)
    xop = if given up trying to accommodate
    esop = if really trying to accommodate
  • Reduced NP accommodation for age
  • Dynamic retinoscopy (shows a lag)
  • Accommodative facility might be reduced: less than 8-10 cycles per minute
72
Q

list 5 clinical sins of accommodative fatigue

A
  • Unable to maintain NP of accommodation x 3
  • Reduced accommodative facility
  • Dynamic retinoscopy normal to begin with, then developing a lag (usually have to be quick, but won’t see the fatigue like this so need to do it slowly in this case)
  • Distance vision normal, near vision initially normal but then reduces over time
  • CT reveals SOP for near over time
73
Q

list 6 possible things you can do for the management of an AI/fatigue

A
  • Fundus examination (pathology treated)
  • Cycloplegic refraction
  • Correct refractive error particularly hypermetropia
  • Extra convex lenses for reading (CRUTCH, so will only stop symptoms, but not get any better)
  • Exercises - will make the accommodation better
  • Down’s syndrome
  • Bifocal’s for short period
74
Q

list 2 types of exercises you can give a patient with accommodative insufficiency/fatigue to do and describe how each one is done

A
  • Lend Flippers
    +/-1.00,+/-1.50 +/-2.00
    Try to increase number of rotations they can clear/minute and do it several times a day
  • Accommodative push ups
    With letters on lollipop stick, ask ox to bring towards their nose and ask to try and keep the letters clear and sharp
    Done for 1-2 minutes
    Monocularly and binocularly
75
Q

list 5 possible aetiologies of accommodative paralysis

A
  • Maybe associated with convergence paralysis
  • Drugs (cycloplegia may accidentally be introduced
    into the conjunctival sac)
  • Psychosomatic
  • Neurological
    Diptheria
    Parinauds
    Total 3rd nerve palsy
  • Trauma
    Blunt causing paralysis of the ciliary muscle
    Closed head injuries
    Whiplash
76
Q

list 3 neurological causes of a accommodative paralysis

A
  • Diphtheria
  • Parinauds
  • Total 3rd nerve palsy
77
Q

list 3 traumatic causes of a accommodative paralysis

A
  • Blunt causing paralysis of the ciliary muscle
  • Closed head injuries
  • Whiplash
78
Q

list 5 signs and symptoms of accommodative paralysis

A
  • No accommodation can be exerted
  • Accommodative facility not possible
  • Large lag with dynamic retinoscopy
  • Burred visual acuity for distances closer than infinity
  • Occurs monocularly and binocularly
79
Q

list 6 possible things that can be done for the management of accommodative paralysis

A
  • Refer urgently if recent onset to ophthalmologist
  • Fundus examination (pathology treated)
  • Aetiology identified and treated
  • Refraction in children, but NOT cyclopegic
  • Correct any hypermetropia or astigmatic error
  • In unilateral paralysis attempt to match the near points of the two eyes by use of multifocal reading addition
80
Q

how will you manage a unilateral accommodative paralysis

A

attempt to match the near points of the two eyes by use of multifocal reading addition

81
Q

list 3 points that describe accommodative inertia

A
  • Difficulty changing focus
  • Difficulty relaxing and exerting accommodation
  • Occurs in both eyes
82
Q

name 2 possible aetiologies with accommodative inertia

A
  • Associated with presbyopia
  • Developing cataract

i.e. elderly patients may mainly complain of this

83
Q

list 3 signs and symptoms of accommodative inertia

A
  • Complains of burred vision when changing from near to distance
  • Distance and near vision: both may be reduced until significant time has passed
  • Take lots of time to investigate near point of accommodation
84
Q

list 4 things that can be done for the management of accommodative inertia

A
  • Fundus examination (pathology treated accordingly)
  • Correct even minimal hypermetropic correction
  • Bifocal reading addition of +1.OO DS may help
  • Orthoptic exercises
    Accommodative flippers
    Improve near point of accommodation (push up accommodation)
    Jump accommodation (like jump convergence but keeping letter clear)
85
Q

list 3 types of orthoptic exercises given to patients with accommodative inertia

A
  • Accommodative flippers
  • Improve near point of accommodation (push up accommodation)
  • Jump accommodation (like jump convergence but keeping letter clear)
86
Q

which is the best orthoptic exercise for accommodative inertia and why

A
  • accommodative flippers

- as it will strengthen both their accommodation and their relaxation

87
Q

what is a advantage and a disadvantage of giving a exercise for accommodative inertia to improve near point of accommodation (push up accommodation)

A
  • advantage: will strengthen their accommodation

- disadvantage: but won’t strengthen/improve their relaxation

88
Q

Which investigation would use in a child where the subjective responses were unreliable?

  • RAF rule
  • Dynamic retinoscopy
  • Flipper lenses
  • Cover test
A

Dynamic retinoscopy

Binocular vision 2 (20 decks)

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