The document discusses various types of heterophoria and vergence abnormalities. It defines heterophoria and describes different types including esophoria, exophoria, hyperphoria and hypophoria. It also discusses causes, symptoms, investigations and treatment of heterophoria. The document further explains concepts related to vergence including near point of convergence, near point of accommodation, fusional amplitudes and AC/A ratio. It describes different vergence abnormalities like convergence insufficiency, divergence insufficiency and near reflex insufficiency.
The document discusses various types of heterophoria and vergence abnormalities. It defines heterophoria and describes different types including esophoria, exophoria, hyperphoria and hypophoria. It also discusses causes, symptoms, investigations and treatment of heterophoria. The document further explains concepts related to vergence including near point of convergence, near point of accommodation, fusional amplitudes and AC/A ratio. It describes different vergence abnormalities like convergence insufficiency, divergence insufficiency and near reflex insufficiency.
The document discusses various types of heterophoria and vergence abnormalities. It defines heterophoria and describes different types including esophoria, exophoria, hyperphoria and hypophoria. It also discusses causes, symptoms, investigations and treatment of heterophoria. The document further explains concepts related to vergence including near point of convergence, near point of accommodation, fusional amplitudes and AC/A ratio. It describes different vergence abnormalities like convergence insufficiency, divergence insufficiency and near reflex insufficiency.
The document discusses various types of heterophoria and vergence abnormalities. It defines heterophoria and describes different types including esophoria, exophoria, hyperphoria and hypophoria. It also discusses causes, symptoms, investigations and treatment of heterophoria. The document further explains concepts related to vergence including near point of convergence, near point of accommodation, fusional amplitudes and AC/A ratio. It describes different vergence abnormalities like convergence insufficiency, divergence insufficiency and near reflex insufficiency.
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HETEROPHORIA AND
VERGENCE ABNORMALITIES DR TEHREEM TANVEER HETEROPHORIA • Heterophoria is defined as a latent tendency for misalignment of the two eyes that become manifest only if fusion between the eyes is dissociated.
• It is a latent strabismus in which the visual axis are
normally directed to the point of fixation but deviate when the eyes are dissociated. CAUSES OF HETEROPHORIA REFRACTIVE ERRORS • Hypermetropia causes esophoria due to over accomodation leading to over convergence • Myopia causes exophoria due to less accomodation leading to less convergence • Oblique astigmatism may cause cyclophoria ANATOMICAL FACTORS: • Orbital assymetry • Abnormal interpupillary distance • Mild degree of extraocular ms weakness
PHYSIOLOGICAL FACTORS • Role of accommodation • Role of convergence TYPES OF HETEROPHORIA • ESOPHORIA: Inward deviation • EXOPHORIA: Outward deviation • HYPERPHORIA: Upward deviation • HYPOPHORIA: Downward deviation • CYCLOPHORIA: Torsional deviation COMPENSATED HETEROPHORIA: • Controlled heterophoria with proper alignment of the eyes and no symptoms as fusional amplitudes are sufficient to maintain alignment. • Accounts for majority of the cases
DECOMPENSATED HETEROPHORIA: • Clinically the pt presents with visual symptoms • Fusional amplitudes are insufficient to maintain alignment • Stress, fatigue, poor health, drugs affecting accomodation, alcohol SYMPTOMS • Asthenopia • Blurred vision • Headache • Diplopia • Distorted images • Difficulty in changing focus from near to far and vice versa • Difficulty in stereopsis INVESTIGATIONS • COVER-UNCOVER TEST • MADDOX ROD TEST • MADDOX WING TEST • PRISM VERGENCE TEST TREATMENT • Smaller degrees of heterophoria which give rise to no symptoms, require no treatment. • Appropriate refractive correction • Orthoptic exercises- esp in convergence weakness exophoria • Symptomatic relief with temporary stick on Fresnel prisms or prisms incorporated in glasses. • Surgery may occasionally be needed for larger deviations. VERGENCE • A vergence is the simultaneous movement of both eyes in opposite directions to maintain a binocular single vision. • It permits stereopsis and prevents diplopia. VERGENCE ABNORMALITIES Vergence abnormalities are disorders of binocular vision which result in either a failure of fusion or an inability to sustain comfortable bifoveal fixation.
Examination of vergence abnormalities include measurement of
• Ocular alignment ( extra ocular movements) • Near point of convergence • Near point of accommodation • Fusional amplitudes • AC/A ratio NEAR POINT OF CONVERGENCE • Nearest point on which eyes can maintain binocular fixation • Measured with RAF rule • Target moved closer until one eye losses fixation and drifts away. • Normal NPC is 10cm. Not changed with age NEAR POINT OF ACCOMMODATION
• Nearest point on which eyes can maintain clear focus.
• Can also be measured with RAF rule. • Focuses on a line of print until it gets blurred. • NPA recedes with age. • At 20 yrs – 8cm, 50 yrs – 46cm FUSIONAL AMPLITUDES/RESERVES
• Measures efficacy of vergence
movements • Can be tested with verticle prism bars or synoptophore. • Prisms of increasing power are placed infront of one eye until diplopia is reported which indicates the limit of fusional amplitude. ACCOMMODATIVE CONVERGENCE/ACCOMMODATION RATIO
• Measurement of convergence induced per diopter of accommodation
• Normal range : 3-5 prism diopter/1 diopter of lens accommodation • High AC/A ratio causes excessive convergence and convergent squint during accomodation • Low AC-A ratio causes divergent squint during accommodation. • Can be measured with heterophoria or gradient method. • HETEROPHORIA METHOD: measures ocular deviation for near and far with full spectacle correction.
IPD in cm, n and d are ocular deviation for near and far in prism diopters, D is near fixation distance in diopters. • GRADIENT METHOD: uses a minus lens to induce accommodation instead of near target.
• More accurate than heterophoria method.
• D is the power of minus lens used to induce accommodation CONVERGENCE INSUFFICIENCY Reduced ability of the eyes to turn inwards on near work. Accommodation insufficiency is occasionally also present. Typically affects school-going children or individuals with excessive visual demand for near work.
Signs : diplopia, headache, blurred vision at near, reduced near point of
convergence and decreased fusional amplitudes.
Treatment : involves orthoptic exercises aimed at normalizing the near point
and fusional amplitudes . with good compliance , symptoms should be eliminated within a few weeks but if persistent can be treated with base-in prisms. For accommodation insufficiency minimum reading correction can be prescribed. DIVERGENCE INSUFFICIENCY • Divergence paresis or paralysis is inability of the eyes to diverge. It is primarily a concomitant esodeviation with reduced or absent divergence fusional amplitudes.
• It is a rare condition usually associated with underlying neurological disease ,
such as intracranial space-occupying lesions, cerebrovascular accidents or head trauma .
• Presentation may be at any age and is difficult to differentiate from sixth nerve palsy.
• Difficult to treat ; prisms are the best option.
NEAR REFLEX INSUFFICIENCY • TRIAD of near reflex: accommodation+ convergence+ miosis
• Paresis of the near reflex presents as dual convergence and
accommodation insufficiency. Mydriasis may be seen on attempted near fixation. Treatment involves reading glasses , base-in prisms and possibly botulinum toxin in lateral rectus . Orthoptic exercises have no effect.
• Complete paralysis in which no convergence or accommodation can be
initiated may be of functional origin, can be caused by midbrain disease or follow by head trauma. Can be reversible. SPASM OF NEAR REFLEX • Spasm of the near reflex is a functional condition affecting patients of all ages (mainly females).
• Signs : diplopia , blurred vision and headaches accompanied by esotropia ,
pseudomyopia and miosis. Spasm may be triggered when testing ocular movements . Observing miosis is the key to the diagnosis .Refraction with and without cycloplegia confirms the pseudomyopia , which must not be corrected optically .
• Treatment involves reassurance and to discontinue any activity that triggers the response . If persistent , atropine and a full reading correction are prescribed. Patients usually seem to live a fairly normal life despite the signs and symptoms. THANKYOU
