Week 7 - Near problems management Flashcards
Management: Refractive error
•Refractive error found should be corrected if it may be the cause of patient’s symptoms or improve convergence.
• Cycloplegia useful.
Could include:
• Correcting myopia which may improve convergence by restoring normal accommodative-convergence relationship.
• Correcting astigmatism may improve symptoms.
• Correcting hypermetropia- may not make convergence worse but improve vision and so, improve convergence.
when are Orthoptic exercises used?
• When compliance is good, orthoptic exercises in convergence insufficiency are effective.
• Exercises are effective if the patient is motivated and symptomatic of diplopia.
• Comprehensive instructions (with demonstration) must be given to the patient regarding:
Aim of exercises:
• Reduce or alleviate patient symptoms.
• Make reading more comfortable.
• Achieve improved near point of convergence: 10cm or less.
Which patients are not suitable for orthoptic exercises?
• Patients who do not have or have not previously had BSV.
• Patients with uncorrected refractive error.
• Patients who are not able to attend the clinic on a regular basis.
• Patients who are not self-motivated to carry out exercises at home.
Improving near point of convergence:
Smooth Convergence
• Patient fixes on an accommodative target e.g., fixation stick and slowly moves it towards their nos
• When diplopia is appreciated, the patient should stop and attempt to join diplopia.
• If it is not possible to join diplopia, the target is withdrawn until single vision is regained.
Jump Convergence
• Using a saccadic vergence movement.
• Patient is instructed to look in the distance and then at a near target.
• The patient should then fix back in the distance and the target is then moved closer to the nose.
• Repeated.
Dot Card:
• Helps with near point of convergence
• Jump convergence can also be achieved with a dot card.
• Based on physiological diplopia.
• Patient fixes on farthest dot.
- Fixes on each closer dot in turn, fusing to make them single.
• The patient can also be instructed to look in the distance and back at the dot.
How often should the exercises be carried out?
• Little and often.
• Approximately: 3x for 2 minutes a day.
• How motivated is your patient?
Voluntary Convergence
• The ability to convergence without the presence of a fusional stimulus.
• Can be taught as a final stage of treatment.
• Ability to do so may be a prognostic sign that symptoms may not recur.
How is this achieved?
• Ask patient to convergence on fine stimulus eg. Piece of string.
- This is removed and patient is encouraged to maintain convergence.
Management Convergence Insufficiency secondary to Convergence Weakness Type Exophoria
• Fresnel prism may be required for near initially to align the eyes before commencing exercises.
• Patient is corrected from EXOTROPIA to EXOPHORIA
• Exercises are commenced to
- 1st: Improve convergence
- 2nd: Improve fusion
How to extend fusional amplitude + improve relative fusional vergence
Management once convergence has been improved…
Extension of the fusional amplitude - enables for comfortable BSV.
• Prism bar- homemade.
• Improve positive: exo
• Improve negative: eso
• Utilises all three components of convergence
Improvement of relative fusional vergence
• Accommodation is constant
• Works on relative vergence
• Based on physiological diplopia
• Stereograms are use
Management of Convergence/Accommodation Spasm
• Treat underlying cause if known.
• Prescription of refractive error.
• Relaxation techniques
• Explanation of cause
• Reassurance
• Sign posting
• Treatment of accommodative component: atropine 1% instilled daily- near work stopped.
Management of Convergence Palsy
• Rule out underlying neurological cause.
• Base In prisms for near if joining possible.
• Exercises after if possible!
• Plus lenses for reading if associated accommodation palsy.
• Occlusion.
Management of Accommodation Anomalies: Accommodation insufficiency
• Treatment of underlying cause.
• Any significant hypermetropia. +0.50DS and +0.75DS can improve patient’s symptoms
• If nil hypermetropia= temporary near add to aid close work.
• If associated with convergence insufficiency= convergence exercises.
Accommodation Facility Exercises
• Patient is given flipper lenses.
• Asked to recognise when image is blurry (same as testing facility)
• When image is seen as blurred, patient is asked to actively “clear the image”.
• Improves the accommodative amplitude.
Management of Accommodation Anomalies: Accommodation Paralysis
• Difficult to treat.
• Treat underlying cause if found during investigation.
• Correct refractive error.
• Plus lenses for reading.
• When unilateral- prescribe to match near point of the other eye.
