Part 1 book “Clinical management of binocular vision heterophoric, accommodative, and eye movement disorders” has contents: Diagnostic testing, general treatment modalities, guidelines, and prognosis, introduction and general concepts, fusional vergence, voluntary convergence, and antisuppression, ocular motility procedures,… and other contents.
CLINICAL MANAGEMENT OF B inoc ula r V is io n H e te ro p h o ri c , Ac c ommodati ve, a n d E y e Movement D i s orders (c) 2015 Wolters Kluwer All Rights Reserved CLINICAL MANAGEMENT OF Bi no cular Vision Hete r op ho r ic , A c c o m m o d a t i v e , and E ye M o v e m e n t D i s o r d e r s Fourth Edi ti on Mitchell Scheiman, O.D Bruce Wick, O.D., Ph.D Professor Associate Dean of Research Pennsylvania College of Optometry at Salus University Elkins Park, Pennsylvania Professor Emeritus University of Houston College of Optometry Houston, Texas Ilustrator Barbara Steinman (c) 2015 Wolters Kluwer All Rights Reserved Acquisition Editor: Ryan Shaw Product Manager: Kate Marshall Vendor Manager: Bridgett Dougherty Senior Manufacturing Manager: Benjamin Rivera Marketing Manager: Alexander Burns Design Coordinator: Teresa Mallon Illustrator: Barbara Steinman O.D., Ph.D Production Service: Integra Software Services Pvt Ltd © 2014 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com Third Edition © 2008 by Lippincott Williams & Wilkins Second Edition © 2002 by Lippincott Williams & Wilkins First Edition © 1994 by J.B Lippincott Co All rights reserved This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Scheiman, Mitchell Clinical management of binocular vision : heterophoric, accommodative, and eye movement disorders / Mitchell Scheiman, Bruce Wick — 4th ed p ; cm Includes bibliographical references and index ISBN 978-1-4511-7525-7 I Wick, Bruce II Title [DNLM: Ocular Motility Disorders—therapy Accommodation, Ocular Vision Disparity Vision, Binocular WW 410] RE735 617.7'62—dc23 2013015242 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 (c) 2015 Wolters Kluwer All Rights Reserved To Maxine, for her love, patience, and understanding —M.S (c) 2015 Wolters Kluwer All Rights Reserved Preface ver the past 19 years we have received very positive feedback from colleagues and students about the first three editions of this book They have remarked that this book is easy to read and understand, and that it provides valuable information about the diagnosis and treatment of binocular vision We have also continued to receive excellent constructive criticism and suggestions and as in the past we have tried to respond to these suggestions in this new edition In both editions and 3, it was necessary to add new chapters to respond to reader suggestions For this edition, however, we have not added any new chapters Rather, the main purpose of this new edition is to refresh the book with the latest research and evidence supporting the evaluation and treatment protocols suggested Over the course of years there have been new research studies and other new literature that are relevant to the topics covered in this text We have carefully reviewed this new literature and have incorporated information from these studies when appropriate One of the other important changes has been the introduction of new technology and equipment for vision therapy We have tried to include information about new vision therapy equipment in this new edition in Chapters 6–8 Finally, all of the illustrations in the book have been updated and a majority of the illustrations are now in color We hope that the updated material will make this fourth edition even more useful than the previous editions for faculty designing courses, students studying these topics for the first time, and established practitioners looking for a practical, easy-to-use reference on accommodative, ocular motility, and non-strabismic vision anomalies O vi Mitchell Scheiman, O.D Bruce Wick, O.D., Ph.D (c) 2015 Wolters Kluwer All Rights Reserved Acknowledgments ne of the authors (M.S.) acknowledges individuals who have had a strong influence on his professional development and the field of binocular vision and vision therapy: Dr Jerome Rosner, who was so instrumental in teaching me how to teach in the very early stages of my career and giving me the push I needed to get involved in didactic teaching; Drs Nathan Flax, Irwin Suchoff, Jack Richman, Martin Birnbaum, and Arnold Sherman, who inspired me to devote my professional career to the areas of vision therapy, pediatrics, and binocular vision; all the investigators of the Convergence Insufficiency Treatment Trial who have helped complete the first large-scale randomized clinical trial of vision therapy for the treatment of convergence insufficiency Dr Michael Gallaway, for his personal and professional support over the last 30 years, Dr. Barbara Steinman, for her outstanding work in designing the illustrations for the second, third, and fourth editions of this book; my family, for their support, and for showing so much patience with me during my many months of writing I (B.W.) wish to acknowledge my father, Dr Ralph Wick, for his assistance and support throughout my career In addition, thanks to Drs Monroe Hirsch, Merideth Morgan, and Mert Flom, who all strongly influenced my development in the field of binocular vision and vision therapy Above all, thanks to my wife Susan for everything O (c) 2015 Wolters Kluwer All Rights Reserved vii Contents Preface vi Acknowledgments vii S ection Diagnostic Testing 2 Case Analysis and Classification 49 General Treatment Modalities, Guidelines, and Prognosis 89 Primary Care of Binocular Vision, Accommodative, and Eye Movement Disorders 112 S ection II Vision Therapy Procedures and Instrumentation Introduction and General Concepts 138 Fusional Vergence, Voluntary Convergence, and Antisuppression 160 Accommodative Techniques 209 Ocular Motility Procedures 221 S ection III Management Low AC/A Conditions: Convergence Insufficiency and Divergence Insufficiency 234 10 High AC/A Conditions: Convergence Excess and Divergence Excess 273 11 Normal AC/A Conditions: Fusional Vergence Dysfunction, Basic Esophoria, and Basic Exophoria 307 12 Accommodative Dysfunction 335 13 Eye Movement Disorders 368 14 Cyclovertical Heterophoria 389 15 Fixation Disparity 429 S ection viii I Diagnosis and General Treatment Approach IV Advanced Diagnostic and Management Issues 16 Interactions between Accommodation and Vergence 451 17 Refractive Amblyopia 471 (c) 2015 Wolters Kluwer All Rights Reserved Contents 18 Nystagmus 491 19 Aniseikonia 517 20 Binocular and Accommodative Problems Associated with Computer Use 547 21 Binocular and Accommodative Problems Associated with Acquired Brain Injury 571 22 Binocular and Accommodative Problems Associated with Learning Problems 593 23 Development and Management of Refractive Error: Binocular Vision-based Treatment 616 24 Binocular Vision Problems Associated with Refractive Surgery 655 S ection V Vision Therapy and Optometric Practice 25 Patient and Practice Management Issues in Vision Therapy 674 Appendices 686 Index 705 (c) 2015 Wolters Kluwer All Rights Reserved ix Chapter 12 / Accommodative Dysfunction TABLE 12.6 353 Differential Diagnosis of Accommodative Excess Functional disorders to rule out Convergence excess Basic esophoria Accommodative insufficiency Accommodative infacility Nonfunctional causes of accommodative excess Bilateral a Drugs Cholinergic drugs Morphine Digitalis Sulfonamides and carbonic anhydrase inhibitors General disease: adults Encephalitis Syphilis General disease: children Influenza Encephalitis Meningitis a Unilateral Local eye disease None General disease: adults Trigeminal neuralgia A bilateral problem may start unilaterally Source: From London R Accommodation In: Barresi BJ, ed Ocular assessment: the manual of diagnosis for office practice Boston, MA: Butterworth-Heinemann, 1984:123–130, with permission DIFFERENTIAL DIAGNOSIS The differential diagnosis of accommodative excess is presented in Table 12.6 Accommodative excess is considered to be a benign condition, with no serious consequences other than the visual symptoms listed in Table 12.5 It must be differentiated from other accommodative disorders The key to the differential diagnosis is that a patient with accommodative excess will perform poorly on all tests that probe the ability to relax accommodation In accommodative insufficiency, the problem will be with minus lenses, and accommodative infacility performance on both plus and minus lenses will be reduced As discussed earlier in this chapter, a less common form of accommodative excess has been reported in the literature that may have an organic cause Spasm of the near reflex has been reported to be secondary to the diseases and medications listed in Table 12.6 These more serious underlying etiologies must be ruled out in all cases of accommodative excess This differential diagnosis depends very much on the nature of the patient’s symptoms Typically, the accommodative excess patient presents with longstanding chronic complaints and a negative health history The history is also negative for any medication known to affect accommodation When managing a case of accommodative excess that is thought to have a functional basis, if symptoms and findings not improve as expected, it is wise to reconsider the etiology of the condition TREATMENT We recommend the management sequence listed on page 335 Lenses Because uncorrected refractive error can be a cause of accommodative fatigue, we recommend that correction of significant ametropia be the first management consideration When dealing with patients with accommodative excess, even small degrees of refractive error may be significant Prescribing for small degrees of hyperopia, astigmatism, and small differences in refractive error between the two eyes may provide some immediate relief of symptoms for the patient (c) 2015 Wolters Kluwer All Rights Reserved 354 Section III / Management Added Lenses Analysis of the near point findings in accommodative excess clearly shows that these patients would not benefit from the use of added plus lenses The low NRA, difficulty clearing plus during accommodative facility testing, the normal amplitude of accommodation, and low MEM retinoscopy are all examples of data suggesting that plus will not be helpful Vision Therapy A vision therapy program for accommodative excess generally requires from 12 to 24 in-office visits, if vision therapy is office based The total number of therapy sessions also depends on the age of the patient and his or her motivation and compliance Specific Vision Therapy Program All of the vision therapy techniques recommended below are described in detail in Chapters to Phase This first phase of therapy is designed to accomplish the objectives listed in Table 12.7 under Phase After establishing a working relationship with the patient and developing an awareness of the various feedback mechanisms that will be used throughout therapy, the first goal of the therapy itself is to improve the patient’s ability to relax accommodation The emphasis during this phase is on the magnitude rather than the speed of the accommodative response Useful procedures include lens sorting, the Hart chart, and loose lens rock Because of the interactions that occur between accommodation and vergence, it is also helpful to simultaneously work with divergence techniques The objective is to help the patient appreciate the feeling and concept of relaxing convergence and accommodation It is therefore helpful to perform divergence procedures during phase Useful procedures include the vectograms, tranaglyphs, and the Computer Orthoptics Random Dot program Home-based therapy procedures are listed in Table 12.8 The HTS software has excellent procedures for both accommodative and vergence therapy Endpoint Phase of therapy ends when the patient can: • Clear +2.00 lenses monocularly with 20/30-size print • Fuse up to 15 Δ using divergence with the tranaglyphs or other convergence technique • Fuse up to 15 Δ using divergence with the Computer Orthoptics Random Dot program A sample vision therapy program for phase is summarized in Table 12.8 This program includes several techniques that can be used by the patient at home to supplement the in-office therapy TABLE 12.7 Objectives of Vision Therapy for Accommodative Excess Phase • Develop a working relationship with the patient • Develop an awareness of the various feedback mechanisms that will be used throughout therapy • Develop feeling of diverging, looking away, relaxing accommodation • Normalize negative fusional vergence (NFV) amplitudes at near (smooth or tonic vergence demand) • Normalize accommodative amplitude and ability to stimulate and relax accommodation Phase • Normalize positive fusional vergence (PFV) amplitudes (smooth or tonic vergence demand) • Normalize NFV facility at near (jump or phasic vergence demand) • Normalize PFV facility (jump or phasic vergence demand) Phase • Normalize NFV amplitudes at intermediate distances • Normalize NFV facility at far (c) 2015 Wolters Kluwer All Rights Reserved 355 Chapter 12 / Accommodative Dysfunction TABLE 12.8 Sample Vision Therapy Program for Accommodative Excess Phase Sessions and in-office • Discuss nature of vision problem, goals of vision therapy, various feedback cues, importance of practice • Lens sorting • Loose lens rock (begin with plus lenses) • Brock string • Tranaglyphs or vectograms: base-in • Begin with a peripheral target such as tranaglyph 515 or the Quoit vectogram • Computer Orthoptics Random Dot program: base-in home therapy • HTS Accommodation program • Loose lens rock • Brock string Sessions and in-office • Hart chart rock • Loose lens rock; plus lenses • Bug on string • Tranaglyphs or vectograms: base-in • Use targets with more central demand (Clown, Bunny tranaglyphs; Clown, Topper vectograms) • Computer Orthoptics Random Dot program: base-in home therapy • HTS Accommodation program • Loose lens rock • Bug on string Sessions through in-office • Hart chart rock • Bug on string • Loose lens rock; add minus lenses • Tranaglyphs or vectograms: base-in • Use even more detailed targets such as tranaglyph Sports Slide and Faces targets and the Spirangle vectogram • Computer Orthoptics Random Dot program: base-in home therapy • HTS Accommodation program • Hart chart rock • HTS Vergence program Phase Sessions and 10 in-office • Loose lens rock; use both plus and minus lenses and incorporate speed as a factor • Tranaglyphs or vectograms with modifications to create jump vergence demand: base-in • Nonvariable tranaglyphs • Tranaglyph 515 or the Quoit vectogram: base-out • Binocular accommodative therapy techniques: use any of the binocular techniques listed above with ± lenses home therapy • HTS Vergence program • HTS Accommodation program • Loose lens rock (emphasize speed) Sessions 11 and 12 in-office • Loose lens rock; use both plus and minus lenses and incorporate speed as a factor • Binocular accommodative therapy techniques: use any of the binocular techniques listed above with ± lenses • Tranaglyphs or vectograms with modifications to create jump vergence demand: base-in • Aperture Rule: base-in • Nonvariable tranaglyphs with ± flip lenses (Continued) (c) 2015 Wolters Kluwer All Rights Reserved 356 TABLE 12.8 Section III / Management Continued home therapy • More central tranaglyphs or the vectograms: base-out Sessions 13 through 16 in-office • Binocular accommodative therapy techniques: use any of the binocular techniques listed above with ± lenses • Aperture Rule: base-in and base-out • Eccentric Circles or Free Space Fusion cards: base-in • Computer Orthoptics Random Dot Vergence program: both base-in and base-out • Tranaglyphs or vectograms with modifications to create jump vergence demand: base-out home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-in Phase Sessions 17 through 20 in-office • Binocular accommodative therapy with ± lenses and the Aperture Rule • Tranaglyphs or vectograms with Polaroid or red/green flippers • Eccentric Circles or Free Space Fusion cards: base-in and base-out • Computer Orthoptics Random Dot Vergence program: step–jump vergence home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-in and base-out Sessions 21 and 22 in-office • Binocular accommodative therapy with ± lenses and the Aperture Rule • Tranaglyphs or vectograms with Polaroid or red/green flippers • Eccentric Circles or Free Space Fusion cards: base-in and base-out • Computer Orthoptics Random Dot Vergence program: jump–jump vergence home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-in and base-out Sessions 23 and 24 in-office • Binocular accommodative therapy with ± lenses and the Eccentric Circles • Tranaglyphs or vectograms with Polaroid or red/green flippers • Eccentric Circles or Free Space Fusion cards with rotation and versions • Computer Orthoptics Vergence program with rotation home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: divergence/convergence with ± flip lenses Phase This second phase of therapy is designed to accomplish the objectives listed in Table 12.7 under Phase In contrast to Phase 1, the speed of the accommodative response should now be emphasized In addition, it is important to begin using minus as well as plus lenses The objective is for the patient to be able to relax and stimulate accommodation as quickly as possible The same techniques used during phase can be repeated using plus and minus lenses, with an emphasis on the speed of the accommodative response We also begin working with BAF procedures, such as red–red rock and bar readers, and binocular facility with targets such as vectograms and tranaglyphs We now incorporate convergence therapy, in addition to divergence therapy, and move toward binocular vision techniques that emphasize phasic vergence changes By the end of this phase, the patient should be using the Aperture Rule and the Computer Orthoptics Random Dot program for both convergence and divergence therapy (c) 2015 Wolters Kluwer All Rights Reserved Chapter 12 / Accommodative Dysfunction 357 Endpoint The endpoint of phase is reached when the patient can: • Clear +2.00/−6.00 lenses monocularly with 20/30-size print, 20 cpm • Clear +2.00/−2.00 lenses binocularly with 20/30-size print, 15 cpm • Fuse card 12 using convergence and card using divergence with the Aperture Rule A sample vision therapy program for phase is summarized in Table 12.8 This program includes several techniques that can be used by the patient at home to supplement the in-office therapy Phase This third phase of therapy is designed to accomplish the objectives listed in Table 12.7 under Phase During phase 3, the emphasis is on integration of accommodation and binocular therapy Phasic binocular techniques such as the Aperture Rule, Eccentric Circles, Free Space cards, and the Computer Orthoptics step–jump vergence program are useful BAF with flip lenses should be used with the phasic binocular techniques listed above It is also important to integrate accommodative and binocular therapy with saccades and versions Moving the Eccentric Circles or Free Space Fusion cards into different positions of gaze or using several sets of cards in various positions, along with flip lenses, is an excellent procedure to accomplish this goal Other techniques, such as the Brock string with rotation and Computer Orthoptics vergence procedures with rotation, are also useful Endpoint The endpoint for this phase of therapy is reached when the patient is able to maintain clear single binocular vision with the Free Space Fusion cards or the Eccentric Circle cards together, while slowly rotating the cards and using +2.00/−2.00 flip lenses As recommended in previous chapters, a reevaluation should be performed about halfway through the therapy program and again at the end of therapy When all vision therapy objectives have been reached and the vision therapy program is completed, we recommend the home vision therapy maintenance program discussed in Chapter (Table 9.10) CASE STUDIES The following case studies (Cases 12.4 and 12.5) are representative of the types of accommodative excess patients that clinicians will encounter in practice Case 12.5 Accommodative Excess Secondary to Convergence Insufficiency Accommodative excess is commonly associated with convergence insufficiency In most cases, the accommodative disorder is secondary to the convergence problem A patient with convergence insufficiency will generally have a receded near point of convergence, exophoria at near, and reduced PFV Such patients often use excessive accommodation to stimulate accommodative convergence to supplement the inadequate PFV If this pattern continues for long periods of time, accommodative excess can occur Refer to Case 9.5 in Chapter for an example Accommodative Infacility BACKGROUND INFORMATION Accommodative infacility is a condition in which the patient experiences difficulty changing the accommodative response level An important characteristic of accommodative infacility is that it is a condition in which the latency and speed of the accommodative response (the dynamics of the accommodative response) are abnormal Thus, it is a disorder in which the amplitude is normal, yet the patient’s ability to make use of this amplitude quickly, and for long periods of time, is inadequate This distinction between amplitude (c) 2015 Wolters Kluwer All Rights Reserved 358 Section III / Management and facility of response is similar to that present for binocular vision anomalies In previous chapters, we described disorders of fusional amplitude, such as convergence insufficiency and convergence excess, and disorders of vergence facility, such as fusional vergence dysfunction Clinicians who only evaluate the amplitude of the accommodative response will invariably miss the diagnosis of accommodative infacility A common issue raised by students and clinicians about this condition is as follows: “If the patient has 15 D of accommodative amplitude, I would expect that he should be able to stimulate and relax D of accommodation.” Many authors have clearly demonstrated that this is not necessarily true (3,5,40–42) It is possible to have a disorder of the dynamics of the accommodative response in the presence of a normal accommodative amplitude A study by Wick and Hall (43) underscores the importance of a clinical assessment of accommodation that includes facility and response, in addition to amplitude They screened the accommodative status of 123 schoolchildren and assessed amplitude, lag, and facility of accommodation Their results indicate that if only one aspect of accommodation is evaluated, there is a reasonable likelihood of missing an accommodative dysfunction A patient may be labeled erroneously as having no accommodative dysfunction when, in fact, one exists There have not been many studies investigating the prevalence of accommodative infacility Hokoda (7), in the study referred to earlier in this chapter, reported that 30% of the accommodative problems found in his sample had accommodative infacility, 55% had accommodative insufficiency, and 15% had accommodative excess Daum (15) found that 12% of the patients with accommodative dysfunction had accommodative infacility Scheiman et al (8) found that 1.5% of the 1,650 children studied had accommodative infacility CHARACTERISTICS Symptoms Most symptoms are associated with reading or other close work Common complaints are blurred vision, difficulty changing focus from one distance to another, headaches, eyestrain, difficulty sustaining and attending to reading and other close work, and fatigue (Table 12.9) The symptom most characteristic of accommodative infacility is difficulty changing focus from one distance to another Daum (15) found that 43% of patients with accommodative infacility complained of this symptom, whereas patients with accommodative insufficiency only mentioned this 7% of the time As with other accommodative and binocular vision disorders, some patients with accommodative infacility may be asymptomatic Avoidance should be considered a symptom of accommodative infacility Signs The signs of accommodative infacility are presented in Table 12.9 Optometric test results that require the patient to both relax and stimulate accommodation will be reduced in accommodative infacility The characteristic findings are poor performance with MAF and BAF testing with both plus and minus lenses, and TABLE 12.9 Symptoms and Signs of Accommodative Infacility Symptoms These symptoms are generally related to the use of the eyes for reading or other near tasks: Long-standing Fatigue and sleepiness Blurred vision, particularly when looking from near Loss of comprehension over time to far or far to near A pulling sensation around the eyes Headaches Movement of the print Eyestrain Avoidance of reading and other close work Reading problems Signs Direct measures of accommodative facility Difficulty clearing −2.00 and +2.00 with monocular a ccommodative facility Indirect measures of accommodative facility Reduced positive relative accommodation and negative relative accommodation Difficulty clearing −2.00 and +2.00 with binocular accommodative facility Low base-out and base-in to blur finding at near (c) 2015 Wolters Kluwer All Rights Reserved Chapter 12 / Accommodative Dysfunction 359 reduced findings with the NRA and PRA The diagnosis of accommodative infacility is used only when there are deficiencies in both stimulation and relaxation of accommodation This is an important distinction because the diagnosis is often based on the results of accommodative infacility testing If a 20-year-old patient, for instance, can only complete cpm during this testing, the term accommodative infacility is often mistakenly used The inability of a patient to complete the expected number of cycles per minute is not sufficient for the diagnosis If the reason for the low number of cycles was difficulty clearing both plus and minus, the diagnosis of accommodative infacility is appropriate If the reason, however, was slow performance with only minus and normal response with plus, or problems with only plus and normal response with minus, the diagnosis is not accommodative infacility The amplitude of accommodation, MEM retinoscopy, and the fused cross-cylinder tests are generally in the normal range As with all accommodative disorders, it is common to find an associated binocular vision disorder Esophoria at near is the most common binocular vision problem associated with accommodative infacility, although exophoria and even intermittent exotropia have been reported (44) ANALYSIS OF BINOCULAR AND ACCOMMODATIVE DATA The entry point into the analysis of accommodative and binocular vision data is the phoria at distance and near In cases of accommodative dysfunction, it is not unusual for the phoria to fall outside expected values As discussed above, accommodative infacility can be associated with exophoria or esophoria Figure 2.4 in Chapter illustrates that after eliminating refractive error and organic causes, the best initial approach is to be concerned about an esophoria or exophoria and to analyze the PFV or NFV group data As the flowchart in Figure 2.5 illustrates, once a binocular vision problem is eliminated, we recommend analysis of the ACC group data In a case of accommodative infacility, these data would reveal a normal amplitude of accommodation and an inability to clear both −2.00 and +2.00 lenses with MAF and BAF, along with reduced NRA and PRA These findings, analyzed as a group, suggest that the patient has difficulty with tests requiring both stimulation and relaxation of accommodation, confirming a diagnosis of accommodative infacility DIFFERENTIAL DIAGNOSIS The differential diagnosis of accommodative infacility is presented in Table 12.10 Accommodative infacility is considered to be a benign condition, with no serious consequences other than the visual symptoms listed in Table 12.10 It must be differentiated from other accommodative disorders The most important test finding in the diagnosis of accommodative infacility is poor performance with MAF testing However, the same is true for all accommodative disorders The key differential is that only in accommodative infacility does the patient have difficulty with both plus and minus lenses With accommodative insufficiency, the patient fails accommodative facility testing because of inability to clear −2.00 lenses, whereas in accommodative excess, the problem is +2.00 lenses There is a great deal of literature suggesting that there may be organic causes for both accommodative insufficiency and excess Similar literature does not exist for accommodative infacility In spite of this lack of documentation, we believe that it is prudent to consider the list of organic causes in Table 12.10 before making any treatment recommendations for accommodative infacility This differential diagnosis depends very much on the nature of the patient’s symptoms Typically, accommodative infacility presents with longstanding chronic complaints and a negative health history The history is also negative for any medication known to affect accommodation When managing a case of accommodative infacility that is thought to have a functional basis, if symptoms and findings not improve as expected, it is wise to reconsider the etiology of the condition TREATMENT We recommend the management sequence listed on page 335 Lenses The first management consideration is correction of ametropia When dealing with patients with accommodative infacility, even small degrees of refractive correction may be significant Prescribing for small degrees (c) 2015 Wolters Kluwer All Rights Reserved 360 Section III / Management TABLE 12.10 Differential Diagnosis of Accommodative Infacility Functional disorders to rule out Convergence excess Basic esophoria Accommodative insufficiency Accommodative infacility Nonfunctional causes of accommodative infacility Bilaterala drugs Alcohol Artane Ganglion blockers Phenothiazides Antihistamines Cycloplegics Central nervous system stimulants Marijuana Cholinergic drugs Digitalis Sulfonamides and carbonic anhydrase inhibitors general disease: adults Anemia Encephalitis Diabetes mellitus Multiple sclerosis Myotonic dystrophy Malaria Typhoid Toxemia Botulism general disease: children Anemia Mumps Measles Influenza Encephalitis Meningitis neuroophthalmic Lesions in Edinger-Westphal syndrome Trauma to craniocervical region (whiplash) Pineal tumor Parinaud syndrome Polyneuropathy Anterior poliomyelitis a Unilateral Local Eye Disease Iridocyclitis Glaucoma Choroidal metastasis Tear in iris sphincter Blunt trauma Ciliary body aplasia Scleritis Adie syndrome general disease: adults Sinusitis Dental caries Posterior communicating artery aneurysm Parkinsonism Wilson disease Midbrain lesions general disease: children Scarlet fever Whooping cough Tonsillitis Diphtheria Lead and arsenic poisoning neuroophthalmic Fascicular nerve III lesion Herpes zoster Horner syndrome A bilateral problem may start unilaterally of hyperopia, astigmatism, and small differences in refractive error between the two eyes may provide some immediate relief of symptoms for the patient Added Lenses Analysis of the near point findings in accommodative infacility clearly shows that these patients would not benefit from the use of added plus lenses The low NRA and PRA, difficulty clearing plus and minus during (c) 2015 Wolters Kluwer All Rights Reserved Chapter 12 / Accommodative Dysfunction 361 accommodative facility testing, the normal amplitude of accommodation, and normal MEM retinoscopy are all examples of data suggesting that plus will not be helpful Vision Therapy A vision therapy program for accommodative infacility generally requires from 12 to 24 in-office visits, if vision therapy is office based The total number of therapy sessions also depends on the age of the patient and his or her motivation and compliance Specific Vision Therapy Program All of the vision therapy techniques recommended below are described in detail in Chapters to Phase This first phase of therapy is designed to accomplish the objectives listed in Table 12.11 under Phase After establishing a working relationship with the patient and developing an awareness of the various feedback mechanisms that will be used throughout therapy, the first goal of the therapy is to improve the patient’s ability to stimulate and relax accommodation The emphasis during this phase is on the magnitude, rather than the speed, of the accommodative response Useful procedures include lens sorting, the Hart chart, and loose lens rock Because of the interactions that occur between accommodation and vergence, it is also helpful to simultaneously work with convergence and divergence techniques The objective is to help the patient appreciate the feeling and concept of looking close and far, converging and accommodating, and diverging and relaxing accommodation It is therefore helpful to perform convergence and divergence procedures during phase Useful procedures include the Brock string, tranaglyphs, and the Computer Orthoptics Random Dot program Home-based therapy procedures are listed in Table 12.12 The HTS software has excellent procedures for both accommodative and vergence therapy Endpoint Phase of therapy ends when the patient can: • Clear +2.00/−6.00 lenses monocularly with 20/30-size print • Fuse up to 30 Δ using convergence and 15 Δ using divergence with the tranaglyphs or other convergence technique • Fuse up to 45 Δ using convergence and 15 base-in using divergence with the Computer Orthoptics Random Dot program A sample vision therapy program for phase is summarized in Table 12.12 This program includes several techniques that can be used by the patient at home to supplement the in-office therapy TABLE 12.11 Objectives of Vision Therapy for Accommodative Infacility Phase • Develop a working relationship with the patient • Develop an awareness of the various feedback mechanisms that will be used throughout therapy • Develop feeling of diverging and converging, looking close and looking far, accommodating and relaxing accommodation • Normalize negative and positive fusional vergence amplitudes at near (smooth or tonic vergence demand) • Normalize accommodative amplitude and ability to stimulate and relax accommodation Phase • Normalize positive fusional vergence (PFV) amplitudes (smooth or tonic vergence demand) • Normalize negative fusional vergence (NFV) facility at near (jump or phasic vergence demand) • Normalize PFV facility (jump or phasic vergence demand) Phase • Normalize NFV amplitudes at intermediate distances • Normalize NFV facility at far (c) 2015 Wolters Kluwer All Rights Reserved 362 Section III / Management TABLE 12.12 Sample Vision Therapy Program for Accommodative Infacility Phase Sessions and in-office • Discuss nature of vision problem, goals of vision therapy, various feedback cues, importance of practice • Lens sorting • Loose lens rock (begin with minus lenses) • Brock string • Tranaglyphs or vectograms: base-out • Begin with a peripheral target such as tranaglyph 515 or the Quoit vectogram • Computer Orthoptics Random Dot program: base-out home therapy • HTS Accommodation program • Loose lens rock • Brock string Sessions and in-office • Hart chart rock • Loose lens rock; minus lenses • Bug on string • Tranaglyphs or vectograms: base-out • Use targets with more central demand (Clown, Bunny tranaglyphs; Clown, Topper vectograms) • Computer Orthoptics Random Dot program: base-out home therapy • HTS Accommodation program • Loose lens rock • Brock string Sessions through in-office • Hart chart rock • Loose lens rock; add plus lenses • Barrel card • Voluntary convergence • Tranaglyphs or vectograms: base-out and base-in • Use even more detailed targets such as tranaglyph Sports Slide and Faces targets and the Spirangle vectogram • Computer Orthoptics Random Dot program: base-out home therapy • HTS Accommodation program • HTS Vergence program • Hart chart rock • Tranaglyphs: base-out Phase Sessions and 10 in-office • Loose lens rock; use both plus and minus lenses and incorporate speed as a factor • Tranaglyphs or vectograms with modifications to create jump vergence demand: base-out • Nonvariable tranaglyphs • Tranaglyph 515 or the Quoit vectogram: base-in • Binocular accommodative therapy techniques: use any of the binocular techniques listed above with ± lenses home therapy • HTS Accommodation program • HTS Vergence program • Loose lens rock (emphasize speed) Sessions 11 and 12 in-office • Loose lens rock; use both plus and minus lenses and incorporate speed as a factor • Binocular accommodative therapy techniques: use any of the binocular techniques listed above with ± lenses (Continued) (c) 2015 Wolters Kluwer All Rights Reserved Chapter 12 / Accommodative Dysfunction 363 TABLE 12.12 Continued • Tranaglyphs or vectograms with modifications to create jump vergence demand: base-out • Aperture Rule: base-out • More central tranaglyphs or the vectograms: base-in home therapy • HTS Accommodation program • HTS Vergence program Sessions 13 through 16 in-office • Binocular accommodative therapy techniques: use any of the binocular techniques listed above with ± lenses • Aperture Rule: base-out • Eccentric Circles or Free Space Fusion cards: base-out • Computer Orthoptics Random Dot Vergence program: both base-in and base-out • Aperture Rule: base-in • Tranaglyphs or vectograms with modifications to create jump vergence demand: base-in home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-out Phase Sessions 17 through 20 in-office • Binocular accommodative therapy with ± lenses and the Aperture Rule • Tranaglyphs or vectograms with Polaroid or red/green flippers • Eccentric Circles or Free Space Fusion cards: base-out • Computer Orthoptics Random Dot Vergence program: step–jump vergence home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-out Sessions 21 and 22 in-office • Binocular accommodative therapy with ± lenses and the Aperture Rule • Tranaglyphs or vectograms with Polaroid or red/green flippers • Eccentric Circles or Free Space Fusion cards: base-in • Computer Orthoptics Random Dot Vergence program: jump–jump vergence home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-in Sessions 23 and 24 in-office • Binocular accommodative therapy with ± lenses and the Eccentric Circles • Tranaglyphs or vectograms with Polaroid or red/green flippers • Eccentric Circles or Free Space Fusion cards with rotation and versions • Lifesaver cards with rotation and versions • Computer Orthoptics Vergence program with rotation home therapy • HTS Vergence program • Eccentric Circles or Free Space Fusion cards: base-in/base-out with ± flip lenses Phase This second phase of therapy is designed to accomplish the objectives listed in Table 12.11 under Phase In contrast to phase 1, the speed of the accommodative response should now be emphasized The objective is for the patient to be able to relax and stimulate accommodation as quickly as possible The same techniques used during phase can be repeated using plus and minus lenses, with an emphasis on the speed of the accommodative response We also begin working with BAF procedures, such as red–red rock and bar readers, and binocular facility with targets such as vectograms and tranaglyphs (c) 2015 Wolters Kluwer All Rights Reserved 364 Section III / Management In addition, we now emphasize phasic vergence techniques By the end of this phase, the patient should be using the Aperture Rule and the Computer Orthoptics Random Dot program for both convergence and divergence therapy Endpoint The endpoint of phase is reached when the patient can: • Clear +2.00/−6.00 lenses monocularly with 20/30-size print, 20 cpm • Clear +2.00/−2.00 lenses binocularly with 20/30-size print, 15 cpm • Fuse card 12 using convergence and card using divergence with the Aperture Rule A sample vision therapy program for phase is summarized in Table 12.12 This program includes several techniques that can be used by the patient at home to supplement the in-office therapy Phase This third phase of therapy is designed to accomplish the objectives listed in Table 12.11 under Phase During phase 3, the emphasis is on integration of accommodation and binocular therapy Phasic binocular techniques, such as the Aperture Rule, Eccentric Circles, Free Space Fusion cards, and the Computer Orthoptics step–jump vergence program, are useful techniques BAF with flip lenses should be used with the phasic binocular techniques listed above It is also important to integrate accommodative and binocular therapy with saccades and versions Moving the Eccentric Circles or Free Space Fusion cards into different positions of gaze or using several sets of cards in various positions, along with flip lenses, is an excellent procedure to accomplish this goal Other techniques, such as the Brock string with rotation and Computer Orthoptics vergence procedures with rotation, are also useful Endpoint The endpoint for this phase of therapy is reached when the patient is able to maintain clear single binocular vision with the Free Space Fusion cards or the Eccentric Circle cards together, while slowly rotating the cards and using +2.00/−2.00 flip lenses As recommended in previous chapters, a reevaluation should be performed about halfway through the therapy program and again at the end of therapy When all vision therapy objectives have been reached and the vision therapy program is completed, we recommend the home vision therapy maintenance program discussed in Chapter (Table 9.10) CASE STUDY The following case study (Case 12.6) is representative of the types of accommodative infacility patients that clinicians will encounter in practice C ase 2.6 Accommodative Infacility History Danny, an 8-year-old third grader, presented with a complaint of blurry vision in school Upon further questioning, it became apparent that his vision was not blurred at all times Rather, he experienced blurred vision when looking up at the board after reading or other close work This was his first eye examination He was healthy and had not been taking any medication Examination Results VA (distance, uncorrected): VA (near, uncorrected): Near point of convergence Accommodative target: Penlight: Cover test (distance): Cover test (near): OD: 20/20 OS: 20/20 OD: 20/20 OS: 20/20 cm cm Orthophoria exophoria (c) 2015 Wolters Kluwer All Rights Reserved Chapter 12 / Accommodative Dysfunction 365 Subjective: OD: +0.25, 20/20 OS: +0.25, 20/20 Distance lateral phoria: Orthophoria Base-in vergence (distance): X/7/3 Base-out vergence (distance): X/20/11 Near lateral phoria: exophoria –1.00 gradient: esophoria Gradient AC/A ratio: 4:1 Calculated AC/A ratio: 5.2:1 Base-in vergence (near): 9/18/10 Base-out vergence (near): 10/20/10 Vergence facility: 13 cpm NRA: +1.25 PRA: −1.50 Accommodative amplitude (push-up): OD: 13 D; OS: 13 D MAF: OD: cpm, cannot clear plus or minus OS: cpm, cannot clear plus or minus BAF: cpm, cannot clear plus or minus MEM retinoscopy: +0.50 OD and OS Pupils were normal, all external and internal health tests were negative, the deviation was comitant, and color vision testing revealed normal function Case Analysis There is no significant refractive error and no indication of any organic problem Because there is no significant phoria, the ACC group data should be analyzed first This analysis indicates that the patient has difficulty with both plus and minus lenses on facility testing and the NRA and PRA These findings, along with the classic symptom of blurred vision when looking from one distance to another, support the diagnosis of accommodative infacility This is an example of a patient who presents with a normal amplitude of accommodation, yet has an accommodative disorder A clinician who only performs accommodative amplitude testing to assess accommodation would routinely miss this diagnosis Management Lenses or added plus lenses were not used in this case because there is no significant refractive error and no indication from the data that plus would be helpful The NRA and PRA are balanced, even though both are low and MEM retinoscopy is normal We therefore recommended vision therapy for this patient and followed the program outlined in Tables 12.11 and 12.12 Twenty-one visits (twice per week) were necessary; after treatment, Danny reported elimination of all blur A reevaluation after vision therapy revealed the following: Near lateral phoria: Base-in vergence (near): Base-out vergence (near): NRA: PRA: Accommodative amplitude (push-up): MAF: BAF: MEM retinoscopy: exophoria 12/24/16 18/34/22 +2.25 −2.50 OD: 15 D; OS: 15 D OD: 12 cpm OS: 12 cpm 12 cpm +0.50 OD and OS (c) 2015 Wolters Kluwer All Rights Reserved 366 Section III / Management Summary and Conclusions Accommodative anomalies occur often, and management of these conditions can be one of the more satisfying aspects of optometric care Patients generally present with bothersome symptoms that interfere with school and work performance We have stressed the importance of assessing all aspects of accommodative function and ruling out any of the organic causes of accommodative dysfunction Once the specific accommodative diagnosis has been reached, treatment using lenses, added lenses, and vision therapy is almost always successful So u rc e o f E qu ipm ent (a) Computer Orthoptics: 6788 Kings Ranch Rd, Ste 4, Gold Canyon, 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