wk6: BV - BV4 Mx and Clinical Care of accom/verg problems Flashcards
List 5 pieces of advice for handling near work demands
Limit amount of near tasks
Pace amount of near work over time (not in one hit)
Adopt harmon working distance (elbow to chin)
Counsel on ideal lighting
Encourage balanced lifestyle
According to US national guidelines, what are the general goals for treating accommodative and/or vergence dysfunction? (4)
- Assist px to function efficiently in activities
- Relieve associated ocular, physical, pahtological symptoms
- Guidelines list specific dysfunction with ideal treatment plan, duration of therapy and prognosis
- Review guidelines biannually
What principles should you consider when managing accommodative vergence problems? (6)
- Why px might have condition + risk factors
- Know risk factors to assist mx
- What is goal of tx?
- Communicate mx options thoroughly with px
- Relate how diagnosis affects px individually
- Discuss consequences of tx
What 5 steps are involved in an overall sequential mx plan for accommodative-vergence disorders?
- Mx any significant Rx
- Counsel px if near workload is risk factor and can be modified
- Mx any accomm probelm first using lens adds
- Consider vision therapy where appropriate
- Consider compensatory options (e.g. prism or lens add) if other options not suitable
Describe the near stress model
states that “most accommodation-vergence dysfunctions follow an etiological path that is assoc. with near visual stress”
When managing co-existing accommodative + vergence disorders, which one should you tx first?
tx accommodative condition first
Name 5 lens mx options for BV problems and say when you would use them
Correct Rx: general principle
Give plus add: for accommodative conditions
GIve minus add: for exo deviations
Use yoked prism: for distance related deviations (e.g. divergence insufficiency)
Use compensatory prism: for large vergence deviations that break into tropia
Which Rx is a risk factor for BV problems?
uncorrected hyperopia
Which accommodative dysfunctions should respond favourably to a plus add?
all of them (plus will support a system that is fatigued or overloaded)
Is minus add a long term solution?
No. Works as a short term solution for exo deviations
Is yoked prism a first line treatment for it’s specific BV problems?
No. Use as a last resort or adjunct to other tx
Is compensatory prism a first line treatment for it’s specific BV problems?
No. Last resort.
Is compensatory prism more useful in adults or children?
more useful in acquired conditions in adult population
Which lens treatment for BV disorders is the most common?
Near pluss add
How much near plus would you typically add to help BV problems? Why?
Typically ranges from +0.75-+1.50. Anything over 1.50 will interfere with working distance in a non-presbyope so most likely won’t tolerat
(“I mx most px with +0.75-+1.25)
When would you consider +1.50 as a near add for BV problems?
When there is a huge eso you want to reduce
When using minus add, how much minus do you typically add?
No more than -2.00 addition
What is yoked prism?
equal prism in each eye in same direction
When using yoked prism, how much prism do you add?
No more than 2^ base up or down to illicit a spatial change/shift is needed
(note: base down lifts image up and further away, vice versa)
When using compensatory prism, how much do you use?
general rule is to use the minimal amount for desired shift or change in vergence that eliminates diplopia
What is the goal of vision therapy?
To re-establish automated effortless accommodative and vergence responses under any stimulus condition
Describe how a structured flow of a vision therapy program with set stages would look like (4) [must know this]
- Monocular - accommodation, fixation skills
- Biocular - transition from monocular to binocular, anti suppression-simultaneous viewing
- Binocular - vergence and accommodation in a binocular environment
- Proficiency - combining skills and adding distractions (i.e. doing it all automatically)
List 3 characteristic findings of convergence insufficiency (3)
Near exo > Dist exo
Abnormal NPC
Reduced Base Out Vergence
List 6 features of a convergence insufficiency tx protocal
- Correct any significant Rx: first tx option
- Educate and counsel: to reduce near stress
- Plus near add if needed: for co-existing accom problems
- VIsion therapy (in office or computer based): to develop better reserves and facility and more efficient voluntary control
- Prism: compensate exo at near
- Referral: for medical opinion if sudden onset, or if illness/trauma suspected
When would you use prism in a px with convergence insufficiency?
to compensate for exo deviation at near when other option s are not effective or practical. (note: use Base In for this)
What do convergence insufficiency treatment trial (CITT) papers conclude? (2)
- Compensatory BI prism glasses no more effective in alleviating symptoms, improving NPC or fusional vergence than placebo Rx
- Pencil push ups not effective in tx convergence insufficiency
Why is office-based VT considered the gold standard approach to tx Convergence Insufficiency? (instead of just doing the therapy at home) (4)
- Program is tailored to suit individual
- Therapy techniques and procedures are individually delivered and supervised in a structured environment
- Optom monitors progress and determines what px should be doing next
- Therapy program follows a goal-based plan with a step by step approach
How do you define convergence excess?
A near deviation at least 3^ more esophoric relative to distance
List 5 characteristic features of convergence excess (note: not all may be present)
High AC/A ratio (in minus direction) Poor response to minus at near Reduced BI facility at near Reduced NRC at near PRA may be reduced
List 6 features of a convergence excess tx protocal
Correct Rx (hyperopia) Educate and Counsel Plus near add VIsion therapy Prism (base out for eso at near, when other options not effective or practical) Referral
What types of near add are there? (4)
single vision near
bifocal
multifocal
interview/access
What are the prognosis of the following: Convergence insufficiency DIvergence excess Basic exophoria Convergence excess Divergence insufficiency Basic esophoria Fusional vergence dysfunction Vertical phorias
Convergence insufficiency: excellent
Divergence excess: good
Basic exophoria: good
Convergence excess: excellent
DIvergence insufficiency: fair
Basic esophoria: good
Fusional vergence dysfunction: excellent
Vertical phorias: good
What are the prognosis of the following: accommodative insufficiency accommodative infacility/ill sustained accommodative excess accommodative spasm
insufficiency: excellent
infacility/ill sustained: excellent
excess: excellent
spasm: fair
Tx options for convergence insufficiency (2) (in order)
VT in office/home
Near add if any accom dysfunction
Tx options for divergence excess (4) (in order, etc.)
VT in office/home
Minus lensdistance add
Base in prism
Surgery
Tx options Basic exophoria (2)
Tx near problem as would a C.I
Tx distance problem as would a D.E
Tx options convergence excess (2)
Plus lens add for near
VT for residual symptoms
Tx options divergence insufficiency (4)
Etiology? if recent onset/acquired
Yoked prism?
VT in office/home
Compensatory prism
Tx options basic esophoria (4)
Tx any hyperopia/near add
Yoked prism?
Vt in office/home
Compensatory prism
Tx fusional vergence dysfunction (2)
VT in office/home
Tx accommodative component with plus
Tx vertical phorias (2)
VT in office/home
Compensatory prism
Tx accommodative insufficiency (2)
Plus add at near
VT in office/home
Tx accommodative infacility/ill sustained (2)
Ous add at near to support system
VT in office/home
Tx accommodative excess (2)
Plus add at near
VT in office/home
Tx accommodative spasm (3)
Plus add for near
VT in office/home
Cycloplegia?
