bva, main lecture, nb videos - cole martin tregaskis … handouts_files... · 2017-03-07 · t h e...
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1
“The Institute of Optometry is unique in being an independent self-financing charity dedicated to
the promotion of clinical excellence, research, and education in optometry.”
Roberson (1989)
Established as London Refraction Hospital in 1922
T H E I N S T I T U T E O F O P T O M E T RYYorkshire Optical Society & Owen Aves
Yorkshire Optical Society (YOS)
Established late 1890s
Predated only by Worshipful Company of
Spectacle Makers
Owen Aves
Brother of Ernest Aves
Pre-eminent optometrist of 1920s
Owen Aves was due to give a lecture to YOS in
1929 but died, and when Mr W Green took over
the lecture he started the tradition of the Owen
Aves Memorial Lecture
Orthoptics for the busy optometrist:
a user-friendly guide
Prof Bruce EvansBSc (Hons) PhD FCOptom DipCLP DipOrth FAAO FBCLA
Director of Research Institute of Optometry
Visiting Professor City, University of London
Visiting Professor London South Bank University
Private practice Cole Martin Tregaskis, Brentwood, Essex
© 1990-2017 Bruce Evans
Reference: Pickwell’s Binocular Vision Anomalies, 5th Edition,
Elsevier, 2007
DISCLOSUREPaid lectures & KOL/product feedback programmes:
Alcon, American Academy of Optometry (UK), Association of Optometrists, Birmingham Focus on Blindness, Black & Lizars, Central (LOC) Fund, Cerium Visual Technologies, College of Optometrists, Coopervision, ESRC, General Optical Council, Hoya, Institute of Optometry, International Institute for Colorimetry, Iris Fund for Prevention of Blindness, Johnson &
Johnson, Leightons, London Vision Clinic, MRC, Norville, Optos, Paul Hamlyn Trust, Perceptive, Scrivens, Specsavers, Thomas Pocklington Trust.
Lecture content always my own
Author of Pickwell’s Binocular Vision Anomalies, editions 3-5
i.O.O. Sales Ltd markets IFS orthoptic exercises, which the speaker designed, and for which he receives a small royalty
Community optometric practice in Brentwood, Essex
PLAN
INTRODUCTION
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from www.bruce-evans.co.uk
For regular tweets on optometric research:
PLAN
INTRODUCTION
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from www.bruce-evans.co.uk
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2
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
OVERVIEW: CAVEAT
Always look for pathology:
Neuro-optometric checks
Pupils, discs, fields, strabismus, incomitancy, accommodation
Check these things regularly
Don’t forget refraction
Change management if not improving significantly
Refer if still not improving
Appropriate re-exam intervals (frequent)
“I’m leaving you Mitchell. You’ve never
had tunnel vision and you never will.”
PLAN
INTRODUCTION
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from
www.bruce-evans.co.uk
For regular tweets on optometric research:
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
3
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
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
Video clip source: CD-ROM in Evans (2007)Pickwell’s Binocular Vision Anomalies, 5th edition
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
Video clip source: CD-ROM in Evans (2007)Pickwell’s Binocular Vision Anomalies, 5th edition
4
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
PLAN
INTRODUCTION
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from www.bruce-evans.co.uk
DISSOCIATED HETEROPHORIA
fusional reservesmotor
fusionfusion lock
sensory
fusion
COMPENSATED or NOT
orthophoria hyperphoria
exophoriaesophoria
KEY SIGNS OF DECOMP. PHORIA
� Symptoms
� Poor cover test recovery
Grade Description
1 rapid and smooth
2 slightly slow/jerky
3 definitely slow/jerky but not breaking down
4 slow/jerky and breaks down with repeat
covering, or only recovers after a blink
5 breaks down readily after 1-3 covers
5.004.003.002.001.000.00
1st appt. mean (TP & BE)
3.00
2.00
1.00
0.00
-1.00
-2.00
-3.00
1s
t a
pp
t. d
iffe
ren
ce
(T
P-B
E)
1.0
1.2
1.4
1.6
1.8
2.0
Scale
Panesar & Evans, in preparation
KEY SIGNS OF DECOMP. PHORIA
� Symptoms
� Poor cover test recovery
� Aligning prism (FD test)
� 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
ALIGNING PRISM: Mallett Unit
• aligning prisms/spheres to eliminate FD
• good foveal and peripheral fusion lock
• question set is important
• ask if a line ever moves
• Karania & Evans (2006)
• for symptomatic phoria:
• sensitivity 75%
• specificity 78%
• Jenkins, Pickwell,
& Yekta (1989)
aged 40 years
and over
under the age
of 40 years
1-SPECIFICITY
1.0.8.6.4.20.0
1.0
.8
.6
.4
.2
0.0
1∆+
1∆+
2∆+
2∆+ 3
∆+
3∆+
5
Orthoptics: stereotests
Lang works well with infants: look at eye movements
Frisby makes a good game with squeaky toy
Recommended from age 2y is Randot
Random dot
Contoured
Norms vary from test to test and evenbetween editions of the same testvan Doorn, Evans, Edgar, Fortuin (2014)
DISSOCIATED HETEROPHORIA
fusional reservesmotor
fusionfusion lock
sensory
fusion
STRABISMUS
NOT COMPENSATED
PLAN
INTRODUCTION
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from www.bruce-evans.co.uk
For regular tweets on optometric research:
sorted!
yes
e.g., Rx
no
REFER
can I correct it?
yes
e.g., hypermetropia
no
REFER
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!
yes
e.g., Rx
no
REFER
can I correct it?
yes
e.g., hypermetropia
no
REFER
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
PLAN
INTRODUCTION
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from www.bruce-evans.co.uk
For regular tweets on optometric research:
6
TREATMENT OF AMBLYOPIA (a)
Many cases never require
full-time occlusion
If 6/9 to 6/25, 2h occ. ≡ 6h
If ≤ 6/30, 6h > 2h
Avoid full time occlusion for
orthotropic anisometropia
Timings approximate
See patients frequently during
the treatment of amblyopia, to
begin with every 4-6 weeks
Flow chart based on review of recent RCTs in Evans et al. (2011; OPO)
Many cases of amblyopia can be cured by refractive correction alone;
20% don’t need occlusion (Gibson, 1955; Pickwell, 1984; Stewart et
al., 2004; West & Williams, 2011)
Contact lenses are likely to be best in anisometropia (Evans, 2006)
TREATMENT OF AMBLYOPIA (b)
Penalisation is a viable alternative to occlusion
West & Williams (2011)
There is a dose-response relationship in patching (Stewart et al, 2004)
Eye patch is best but compliance poor & they will cheat!
RCTs show that occlusion is unsuccessful in 17-37% (Simons, 2005)
If treatment fails, re-evaluate your diagnosis (Evans, 2007)
Treated amblyopic eyes on average 2 lines below fellow (Repka et al., 2005)
Remember that the child may be partially sighted during occlusion
It is not always better to do something than nothing at all (Jennings, 2005)
Record informed consent
MOTOR DEVIATION:
REFRACTIVE CORRECTION: OVERVIEW
• Mandatory in accommodative esotropia
• Also possible to treat exo-deviations
with negative lenses & convergence
excess with multifocals
• limited by 4 factors
– angle of deviation
– refractive error
– accommodation
– AC/A ratio
MOTOR DEVIATION:
REFRACTIVE CORRECTION: SPECIFICS
• determine sphere that
– eliminates strabismus (no diplopia)
– eliminates FD on Mallett Unit
• Can check (2 mins) don’t adapt (North & Henson,
1985)
• prescribe, try to reduce approx. every 3-6/12
• negative adds (Chen et al., 2016) and
bifocals/varifocals can work well
MOTOR DEVIATION:
REFRACTIVE CORRECTION: MYTHS
• negative adds might cause myopia
– overminus lenses do not induce clinically significant myopic
changes (Rutstein et al., 1989; Paula et al., 2009)
• patient likely to adapt to the over-correction
– if abnormal BV, tend not to adapt (North & Henson, 1985)
• bifocals might reduce children’s ability to accommodate
– smooth muscle; 14D-3D=11D
– BF don’t reduce amplitude of accommodation (Fresina et al,
2010)
• accommodative (hyperopic) esotropia will not need glasses in
later life
– after 10 yrs, 97% still need Rx (Rutstein & Marsh-Tootle, 1998)
MOTOR DEVIATION:
REFRACTIVE CORRECTION: CASE STUDY: D1542
• 11/5/96, female, age 8y, 1 headache a fortnight
– wearing full cyclo plus (c. +2.00, R=L)
– cover test: D: 8∆ SOP N: 10∆ RSOT
– with +2.00 add: N 4∆ RSOT with +2.50 add: N ortho
Date May 96 July 96 Mar 97 Jun 97 Sep 97 Jan 98 Apr 98 Jun 98 Sep 98Add +2.50 +3.00 +2.50 +2.00 +1.75 +1.50 +1.00 +0.50 None
7
MOTOR DEVIATION:
PRISMATIC CORRECTION: OVERVIEW
• preferred treatment in
small/moderate vertical deviations
• may also help in small/moderate
horizontal deviations if not
amenable to refractive modification
or exercises
• limited by angle of deviation /
cosmesis of prism“There I was, asleep in this little
cave here, when suddenly I was
attacked by this hideous thing with
five heads!”
MOTOR DEVIATION:
PRISMATIC CORRECTION: SPECIFICS
• determine prism that
– eliminates strabismus (no
diplopia)
– eliminates FD on Mallett Unit
• unlikely to adapt to prism if
abnormal BV (North & Henson,
1985)
• But can check (2 mins) don’t adapt (North & Henson, 1985)
MOTOR DEVIATION: PRISMATIC CORRECTION: EVIDENCE
0.5PD
1PD1.5PD
3PD
2PD
2.5PD0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.2 0.4 0.6 0.8 1
1-Specificity (false alarm rate)
Sen
sit
ivit
y (
Hit
rate
)
O’Leary and Evans (2006)
Small RCT (mostly esophoria) shows Mallett prism preferred to no prism"Based on our results, one would not expect
to find a significant preference for prism
prescribed according to Sheard's criterion.” Payne et al., 1974
Mallett prism improves stereoacuity Abd Manan et al., 2001
Prism prescribed using Sheard’s criterion is no better than placebo for children with CI Scheiman et al., 2005
RCT: Mallett prism improves reading speed O’Leary & Evans, 2006
Presbyopes with CI have fewer symptoms with BI prism Teitelbaum et al., 2009
Prismatic glasses (8BI) as effective as computer orthoptics at improving reading Dusek et al., 2011
Vertical prism improves postural stability, especially if chronic lower back pain Matheron & Kapoula, 2008, 2014
MOTOR DEVIATION:
FUSIONAL RESERVE EXERCISES:
OVERVIEW
• preferred treatment in small/moderate
horizontal deviations, if px co-operative
• Work well in those aged 11-19y, even if
strabismic (Pickwell & Jenkins, 1982)
• in exo-deviations improve ability to converge
• in eso-deviations improve ability to diverge
• try to assess progress using a method
different to the treatment technique
• there is some supporting evidence from RCTs
– Ciuffreda & Tannen (1995)
– Scheiman & Gwiazda (2011)
It was over. But the way the
townsfolk called it, neither
man was a winner.
CONVERGENCE INSUFFICIENCY: SPECIFICS
Treatments (in order of increasing complexity)
simple push up (bead on string if very remote)
jump convergence
push up with physiological diplopia
jump convergence with physiological diplopia
free-space stereograms
RCT shows intensive programme of exercises better than home push-up Scheiman et al. (2005)
15min a day + 60min weekly > 15min a day
“Whether synoptophore or jump vergence stereocards are used…the critical variable is the length of time it is maintained” Vaegan (1979)
“Convergence exercises independent of accommodation were the most effective treatment” Horwood & Toor (2014)
FUSIONAL RESERVE EXERCISES:
COMPUTER ORTHOPTICS
HTS
Wide range of vision therapy (USA)
For fusional reserves, amblyopia& much more (if wanted!)
In-office & at-home
Orthoweb
Designed by Andrew Field
Patient “visits” web site for exercises
http://www.academy.org.uk
BV Trainer
Designed by David Fleischmann
iPad or iPhone
8
DEVELOPMENT OF IFS: Primary goal
• To maintain the
patient in an over-
converged posture for
10-20 mins a day
without them becoming bored
• To provide a variety of
stimuli to help any
benefit translate into
everyday life
• Declaration of interest
IFS EXERCISES: USES
• IFS exercises can be used to treat:
• decompensated exophoria at near
• binocular instability
• convergence insufficiency
• intermittent exotropia at near
• experienced practitioners can also use the exercisesto treat constant comitant exotropia at near, usually
as part of a more detailed treatment regimen.
DEVELOPMENT OF IFS:
Card 1
• Teaches physiological diplopia
& introduces 3-D perception
Card 1: Learning How to Use Double Vision to Develop 3-D Vision On the “Card 1” that accompanies these notes there are three "exercise pictures". These
pictures look very simple. But don't be fooled! As you will come to realise, these exercises will involve you doing some very clever things with your eyes.
Card 1: First Exercise: Dots Stage 1: Seeing Four Dots
The first of the three exercises on Card 1 consists of two dots, about 1.5 cm apart. The aim of these dots is to teach you how to use double vision to improve your control over your eyes. These dots are like those drawn below.
. . Look at the dots, then try and make your eyes "go cross-eyed" (try imagining that you are
looking at something on the tip of your nose. When you do this you should notice that the dots go double, so that you see 4 dots instead of 2, as drawn below. At the moment, don't
worry if the dots become blurred.
. . . .
DEVELOPMENT OF IFS:
Card 2
• Builds fusional reserves (step &
ramp)
• Controls for & treats suppression
FREE SPACE STEREOGRAMS
Card 2: Improving 3-D Vision
Card 2: Improving 3-D Vision: Mega 3-D ! After completing card 1 you will not be surprised by the pictures on card 2. What you can see
is 5 pairs of targets, each target is made up of 2 rings, with other shapes as well. Before long,
these shapes will be floating off the page towards you, in a type of “virtual reality”. The
smaller targets are at the top of the page; and the targets become further apart towards the
bottom of the page. Surprisingly, the smaller top two targets are actually easier to do than the
larger ones. So start with the smaller targets.
Stage 1: The Smallest Targets For now, try to ignore the larger targets and just concentrate on the smallest size at the top of
the page. Don’t think about the shapes: at this stage just concentrate on the rings. The
procedure is exactly the same as for the circles on Card 1. However, there are no dots so you
have to make your eyes go cross-eyed without using the dots.
As before, make your eyes go cross-eyed (you can use a pencil if you have to) until you see 4
blurred targets instead of 2. Then, change how cross-eyed you are until you see 3 targets. The
inner rings on the central target should look like they are closer to you than the outer ones. IF
THE INNER RING SEEMS FURTHER AWAY THEN STOP DOING THE
EXERCISES AND TELL YOUR EYECARE PRACTITIONER.
Practice keeping three targets instead of two or four. You may need to twist the page to keep
the targets level. Try to keep the targets as clear as possible. When you can see 3 targets and
keep them clear for most of the time then go on to Stage 2.
DEVELOPMENT OF IFS:
Card 3
• Builds fusional reserves
• Controls for suppression
• Card 4 similar, but different
autosterogram
Card 3: Now to Magic!Unlike Cards 1 and 2, Card 3 should be turned on its sideto be viewed, so the heading is at the top. When you lookat Card 3 you will probably not be able to see a lot, exceptfor a few eyes looking out at you from near the top of thepicture. Believe it or not, when you can do this exerciseyou will be able to clearly see letters on this sheet. What’smore, these letters will appear in 3-D.
The type of picture on Cards 3 and 4 is called anautostereogram. Recently, the autostereogram method ofseeing 3-D images has become very popular, and youhave probably seen posters, postcards, books, and evenvideos using this type of picture. It may be that you havealready experimented with these images, and you may ormay not have managed to see them in 3-D.
With this type of picture there are in fact 2 ways of seeingthe image in 3-D. The way most people use is to under-converge the eyes. Because your eyes naturally under-converge, this method will be easiest for you. If you canalready see 3-D images in this type of picture then it isalmost certainly because you use the under-convergencemethod. However, the under-convergence method willnot help your eye problem. The stages described belowwill teach you a new way to see the 3-D images, by over-convergence. This method is similar to that used onsheets 1 and 2 and will help your eyes to become better atworking together.
OPEN TRIAL: Fusional reserves &
NPC (N=20)
• Divergent reserves
(control) did not
change significantly
(p=0.6)
• Convergent
reserves improved
significantly
(p=0.004)
• Mean NPC
improved from 6 to 4
cm (p=0.015)0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
Prism
Diopters
convergent reserve divergent reserve
Mean Fusional Reserves (to break)
initial
final
Evans (2000)
9
OPEN TRIAL: Effect of treatment on compensation
Cri ter ion Before Af ter C h i - s q a r . W i l c o x o n
Mal l e t t 8 passed 14 passed 0 . 006 0 .03 5
Sheard 7 passed 14 passed 0 . 001 0 .02 5
To SpL
DEvans (2000)
3-D displays are popular but unnatural
Vergence changes but accommodation does not
Loss of spatial resolution (but may help) OR
Loss of temporal resolution
Unusual degrees of stereopsis
Possible mismatch between various depth cuesHowarth (2011)
People with borderline binocular vision are more likely to have problems with 3-D displays
Lambooij, Fortuin, Ijsselsteijn, Evans, Heynderickx (2010)
How many people will not perceive 3-D content?
Strabismus 2.5-4%
Uncorrected anisometropia 0.5-1.5%*
Monovision 0.4%*
Stereo-blind <0.1%*
Poor or distorted vision in one eye v rare in young*
Total 3.5-8%
Under-corrected refractive error 11-30%*
Decompensated heterophoria possibly, 1-10%*
*more common in older people
Could be reduced with better eyecare
How many people may have discomfort with 3-D?
PLAN
SYMPTOMS
INVESTIGATION OF INCOMITANCY
INVESTIGATION OF HETEROPHORIA
INVESTIGATION OF HETEROTROPIA
TREATMENT
CONCLUSIONS
Full handout of slides from www.bruce-evans.co.uk
For regular tweets on optometric research:
CONCLUSIONS
Always be on the lookout for pathology
refer if no significant improvement
BUT pathology is very rare
It is possible to treat amblyopia in optometric practice
patients will need good instructions & regular checks
Many comitant ocular motor anomalies are treatable
plus for eso and minus for exo are under-used treatments
Vision therapy for convergence insufficiency is evidence-based, but there is a need for more research for other forms of vision therapy
Dr Optometry
In 2008 the Institute of Optometry launched a Doctor of Optometry degree in collaboration with London South Bank University
5 year part time professional doctorate
Year 1 has 13 taught days & 2 assignments
Year 2 has 8 taught days & 2 assignments
Years 3-5 are supervised doctoral research
� Research most likely to be clinical, in practice
“the ultimate HQ for UK optometrists”
10
“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