INTRODUCTION binocular vision anomalies … handouts_files/20150617... · binocular vision...

1

Optometric investigation of

binocular vision anomalies

Prof Bruce EvansBSc (Hons) PhD FCOptom DipCLP DipOrth FAAO FBCLA

Director of Research Institute of OptometryVisiting Professor City UniversityVisiting Professor London South Bank UniversityPrivate practice Cole Martin Tregaskis, Brentwood, Essex

© 1990-2015 Bruce Evans

Reference: Pickwell’s Binocular Vision Anomalies, 5th Edition, Elsevier, 2007

PLAN

INTRODUCTION

INVESTIGATION OF INCOMITANCY

INVESTIGATION OF HETEROPHORIA

INVESTIGATION OF HETEROTROPIA

CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk

For regular tweets on optometric research:

PLAN

INTRODUCTION




CONCLUSIONS


For regular tweets on optometric research:Optometry & orthoptics

5% of YOUR patients will have

BV problems

83-100% of eye exams by

community optometrists include

an orthoptic assessment

Shah, Edgar, Evans (2008)

Daily Mail, July 17, 2001

Orthoptics & low vision

30 subjects with VA of 6/60 or better,

23 of whom had ARM

Many found to have binocular vision

(BV) anomalies and asthenopic

symptoms

Authors argued need LV & BV

assessments

Rundstrom & Eperjesi (1995)

PLAN

INTRODUCTION




TREATMENT

CONCLUSIONS

Full handout of slides from

www.bruce-evans.co.uk


2

CAUSES OF PARESES

Diabetes

Hypertension

Stroke

Aneurysms

Temporal

arteritis

Tumours

Multiple sclerosis

Myasthenia gravis

Migraine

Trauma

Thyrotoxicosis

Toxic

Iatrogenic

Idiopathic

Underlined = more likely in elderly

Image courtesy of John O’Donnell

Motility test

Use reliable pen torchCheck nose not occluding

Really, three tests, so do three times:1) Observe corneal reflexes

2) Cover test in peripheral gaze

3) Ask about diplopia

Beware of reports of diplopiaMay break down (in view of target, distance, fus. res.)

May be variable

May be confused

Know the muscle actions (RADSIN)

ACTIONS OF SUPERIOR MUSCLES MOTILITY DIAGRAM

IO

SO

SR

IR

MR LR

IO

SO

SR

IR

MRLR

3

ACTION IN PRIMARY POSITION/POSITIONS OF MAXIMUM POWER

ACTIONS IN PRIMARY POSITION

IO SR � �

LR � RIGHT �MR

� � SO IR

POSITIONS OF MAXIMUM POWER SR IO � �

LR � RIGHT �MR

� � IR SO

AHPs: Can I help you?

AHPs are usually there to helpThe head will be tilted, tipped, or turned in the direction in which the palsied muscle ought to be moving the eye

Indicates that the patient has or has had the potential for BSV

Exception is rare cases where px prefers to have large angle of diplopia

In recent palsy, if cover eye AHP goes

Look also for facial asymmetrye.g., LSO

Primary & secondary deviations

+ + + +

FIXING FIXING

+ + + _ _ _

SECONDARY DEVIATIONFIXING

_ _ _

+ + +

FIXINGPRIMARY DEVIATION

+

SO palsy: the nightmare muscle

Nightmare to detect on motility testing

Nose gets in the way

Lids obscure view

Torsional deviation

Nightmare to detect because of secondary sequelae

Michelangelo’s David

4

PARKS THREE STEPS METHOD

consider R hypo-deviation to be L hyper-deviation

1. Is it R/L or L/R?R/L: RSO, RIR, LIO, LSR L/R: RIO, RSR, LSO, LIR

2. Is the vertical deviation greater in R or L gaze?R gaze: RSR, RIR, LIO, LSO L gaze: RIO, RSO, LSR, LIR

3. Is the vertical deviation greater with head tilt to R or L?R tilt: RSO, RSR, LIO, LIR L tilt: RIO, RIR, LSO, LSR

CONCLUSION: PARETIC MUSCLE(S):

1. Ipsilateral hypertropia I2. Contralateral gaze increases deviation C3. Ipsilateral head tilt increases deviation I

Bielschowsky head tilt test

RADSIN: superiors intort� e.g., no palsy, head tilted to right

� RSR and RSO innervated to intort� RSR elevates, counteracting RSO (depresses)� So no vertical movement

� If RSO palsy, when head tilted to right� RSR excessively innervated to intort� RSR elevates, not counteracted by RSO� So RE moves up

LINDBLOM’S METHOD

70cm rod at 1m, or double Maddox rods (<10° one SO)

Where there is maximum diplopia, are the two images parallel or torsional?

parallel: RSR, RIR, LSR, LIR torsional: RSO, RIO, LSO, LIO

If parallel:1. Where is the vertical diplopia greatest?

upgaze: RSR, LSR downgaze: RIR, LIR

2. Does the separation increase on R or L gaze?

R: RSR, RIR L: LSR, LIR

CONCLUSION: PARETIC MUSCLE(S):

Lindblom, Westheimer, Hoyt (1997)

LINDBLOM’S METHOD

70cm rod at 1m, or double Maddox rods (<10° one SO)

Where there is maximum diplopia, are the two images parallel or torsional?

parallel: RSR, RIR, LSR, LIR torsional: RSO, RIO, LSO, LIO

If torsional:

1. Does the illusion of tilt increase in upgaze or downgaze?

upgaze: RIO, LIO downgaze: RSO, LSO

2. Does the intersection of the rods point to the R (>) or L (<) or is it crossed?

R: RSO, RIO L: LSO, LIO

3. If crossed, (X) does the tilt angle increase in upward gaze or downward?

upgaze: bilateral IO paresis (very unlikely) downgaze: bilateral SO paresis

5

Neurogenic v. mechanical palsies

Feature Neurogenic Mechanical

Underaction during motility

Gradually apparent

Abruptly apparent

Secondary sequelae

Apparent (unless new)

Absent

IOP in gaze positions

Similar Increases in restriction

Saccadic velocities

Slow Close to normal

Common incomitancies seen in optometric practice

Superior oblique palsy

Duane’s syndrome

Lateral rectus palsy

Brown’s syndrome

Become familiar with what these look like:

CD in Pickwell’s Binocular Vision Anomalies, 5th

edition

SO palsy

Usually:

Hyper-deviation of affected eye, worse in down-gaze

under-action of affected eye when looking down and in

More likely to have symptoms with reading than with distance

But, may have secondary sequelae

Avoid fitting multifocal spectacles or monovision

Video clip source: CD-ROM in Evans (2007)Pickwell’s Binocular Vision Anomalies, 5th edition

Duane’ssyndrome

Retraction of the globe on attempted adduction

Co-contraction of medial and lateral recti

Not all cases exhibit retraction

Limitation of abduction and/or adduction in one or both eyes

Can look like a lateral or medial rectus palsy

May also be elevation or depressionof affected eye

Convergence is very often abnormal, even when adduction appears to be intact


Brown’ssyndromeMechanical restriction of the superior oblique

Looks like inferior oblique (IO) palsy

But IO palsy is much rarer & has:

Secondary sequelae

Incyclodeviation in primary position

Positive Parks three step test


Incomitancies: conclusions

Some incomitancies are difficult to detect

2/3 of diplopic hypertropic pxs OK on motilityTamhankar et al (2011)

If symptoms are suspicious, do cover testing in peripheral gaze

Testing for cyclo-deviations detects SO palsies

Refer new or changing incomitancies

In some long-standing cases, prescribing the prism required in the primary position may help

6

PLAN

INTRODUCTION




CONCLUSIONS


DISSOCIATED HETEROPHORIA

fusional reservesmotorfusion

fusion locksensoryfusion

COMPENSATED or NOT

KEY SIGNS OF DECOMP. PHORIA

Symptoms

Poor cover test recovery

Aligning prism

Low fusional reserve opposing phoria Sheard’s criterion Particularly useful for exophorias

For esophorias, size and imbalanced fusional reserves are relevant

For hyperphorias, size matters

KEY SIGNS OF DECOMP. PHORIA

Symptoms


Aligning prism (FD test)




KEY SIGNS OF DECOMP.PHORIA


Aligning prism




KEY SIGNS OF DECOMP.PHORIA


Aligning prism




7

DISSOCIATED HETEROPHORIA

fusional reservesmotorfusion

fusion locksensoryfusion

STRABISMUS

NOT COMPENSATED

PLAN

INTRODUCTION




CONCLUSIONS



sorted!

yese.g., Rx

noREFER

can I correct it?

yese.g., hypermetropia

noREFER

do I know the cause?

yes

any treatment needed?(probably not)

no

is it new or changing?

Strabismus: the bottom line for the busy optometrist

A

M

B

L

Y

O

P

I

A

Strabismus: the bottom line for the busy optometrist

sorted!

yese.g., Rx

noREFER

can I correct it?

yese.g., hypermetropia

noREFER

do I know the cause?

yes

any treatment needed?(probably not)

no

is it new or changing?

A

M

B

L

Y

O

P

I

A

MOTOR DEVIATION: MEASUREMENT

dissociation tests “can” measure the deviation

BUT measurement may be confounded by suppression or HARC

some covering/uncovering may be necessary

BUT try to avoid building up the angle to the total angle

different test methods give different results

cover-uncover test may be the purest measurement

results may vary at different times in a given patient

MOTOR DEVIATION: INVESTIGATION OF

DIPLOPIA

O X OO X O O X OO X OO X OO X OO X OO X O

The last thing a fly ever sees

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MICROTROPIA:

SUGGESTED DIAGNOSTIC CRITERIA

Evans (2007) Pickwell’s Binocular Vision Anomalies, 5th Edition, Elsevier,

PLAN

INTRODUCTION




CONCLUSIONS

Full handout of slides from http://homepage.virgin.net/bruce.evans

CONCLUSIONS

Always be on the lookout for pathology

refer if no significant improvement

BUT pathology is very rare

Differential diagnosis of binocular vision anomalies is an important part of optometric practice

Sudden Onset DiplopiaYoung

trauma

demyelinating disease

tumours

Elderlyusually vascular

history of high BP, poor circulation, diabetes

Elicit time-span

Refer promptly

Of particular concern...IIIN palsy - vascular or aneurysm ?

Diabetes or hypertension usually ‘spares’ the pupil - ptosis and strabismus only

Urgent GP referral (or ocular emergency)

intracranial aneurysm (usually of posterior communicating artery) usually also affects externally placed pupillary fibres and results in strabismus, ptosis and dilated pupil

ocular emergency

“We find comfort among those who

agree with us –growth among those

who don’t.”Frank A. Clark

Some famous people who were dyslexic

Thomas Edison, Albert Einstein,Michael Faraday, Willem Hollenbach,Orlando Bloom, Tom Cruise, DannyGlover, Whoopi Goldberg, KeanuReeves, Oliver Reed, David Bailey,Leonardo da Vinci, Tommy Hilfiger,Pablo Picaso, Auguste Rodin, AndyWarhol, Duncan Goodhew, Cher,John Lennon, King Carl Gustav,Winston Churchill, Michael Heseltine,John F Kennedy, Nelson Rockefeller,George Washington, Hans ChristianAnderson, Agatha Christie, F. ScottFitzgerald, Richard Branson, F.W.Woolworth, Walt Disney, W.B. Yeats.

Handout from www.bruce-evans.co.uk for regular tweets on optometric research

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