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Professor Bruce JW Evans BSc (Hons), PhD, FCOptom, DipCLP DipOrth, FAAO ,
Everyday optometric orthoptics
Top tips and how to specialise
rthoptics is defined as, “The study, diagnosis, and non-surgical treatment of anomalies of binocular vision, strabismus, and monocular functional amblyopia”1. Binocular vision (orthoptic) anomalies affect at least 5% of the population and some say that the prevalence is much higher than this. All optometrists will inevitably encounter patients with orthoptic anomalies, and they must be able to recognise these conditions and deal with them appropriately, either by treatment or referral. In other words, orthoptics is not an optional subject for practising optometrists and this is why all optometry training courses and the PQE examinations cover orthoptics/binocular vision anomalies.
guidelines on orthoptics, the section on ‘Examining the Younger Child’ is relevant. • Specialist practice. Primary eyecare in the UK is almost synonymous with optometry, and as the optometric profession matures, it is only natural that we are seeing an increasing degree of specialisation within the optometric profession. One of these areas is orthoptics, and indeed the COptom Diploma in Orthoptics2 was the first postgraduate orthoptics qualification in the UK. It is not possible in one article to provide a comprehensive review of orthoptic techniques at any of these three levels. This article provides an overview of the subject, with some ‘top tips’ which it is hoped will be useful for the busy practitioner. Where relevant, the three levels of practice are used to provide a suggested context for some of the procedures that are discussed.
What you need to know about orthoptics
Although all optometrists need to have a working knowledge of orthoptics, it is only a minority who choose to specialise in this subject. As with any area of professional practice, optometric skill levels in orthoptics can be considered at three levels: • Minimum level of basic knowledge for safe practice. The most important reason to be ‘safe’ is for the patient’s benefit. A secondary reason in these litigious times is for the practitioner’s safety. In the case of a complaint to the GOC or of civil litigation, you may have to show that there is at least a body of reasonably competent optometrists who would have practised in the way that you did. • Good practice. The College of Optometrists (COptom) guidelines are on the College website at www.collegeoptometrists.org under the heading of ‘Good Optometric Practice’. Although there is no specific section in the
exclusive. For example, a child with strabismic amblyopia, where the cause of the strabismus is not clear, may be referred for medical investigation, but whilst waiting for the hospital appointment, the optometrist might start patching. As in all healthcare sciences, the diagnosis and management are not fixed entities, but rather are the latest judgements based on the best available evidence at that time. Very often, one treatment is tried in the first instance and if this is not effective, then a second choice treatment will be tried. Practitioners should always try to keep an open mind about their diagnosis and should be prepared to constantly reconsider this in light of their latest findings, and of the patient’s response to treatment.
Detecting and diagnosing incomitant deviations
The most commonly used test for detecting incomitant deviations is the ocular motility test. Most optometrists do not perform this on every patient they see4, but it is good practice to perform this test on every new patient, every time a young child is seen, and every time a patient with suspicious symptoms (e.g. diplopia) or signs (e.g. change in cover test results) is seen. A motility test is essential in every case of (suspected) binocular vision anomalies. In the sections of this article on heterophoria and strabismus, it is assumed that the practitioner has ruled out incomitant deviations. Although the motility test sounds simple, it can be very difficult to diagnose an underacting muscle by this test alone. There are really three different motility tests: the objective motility test in which the corneal reflexes of the light target are observed; the cover test in peripheral gaze; and the subjective motility test where the practitioner records changes in diplopia in different positions of gaze. When an incomitancy is detected, it can be confusing to try to interpret these three test results simultaneously, and it can be easier to do them separately. A worksheet for recording the results of these three tests can be found in Appendix 8 of Evans (2002)3. New, or changing, incomitant deviations can be a sign of pathology and require referral; this is mandatory as basic safe practice. The urgency of referral depends on the age, severity, and speed of onset. To take the most extreme example, a sudden onset third nerve palsy requires an emergency referral. Just as in perimetry, good practice would be to evaluate field defects detected with supra-threshold testing using
Reasons for intervening when an orthoptic anomaly is present 1. If the anomaly is causing symptoms or decreased visual function 2. If the anomaly is likely to worsen if left untreated 3. If the anomaly is likely to be a sign of ocular or systemic pathology
Top tips for everyday optometric orthoptics
When do I need to do something about an orthoptic anomaly?
As a general rule, there are only three reasons for intervening when a binocular vision anomaly is present3. These are listed in Table 1. It should be noted that not all patients with symptoms are aware of these. This is especially true of children, who may only appreciate that a symptom was present once the condition has been successfully treated. It is only very rarely that binocular vision anomalies are encountered in primary eyecare practice which result from ocular or systemic pathology, but practitioners must always be alert to this possibility (Table 5).
Interventions for binocular vision anomalies. The suitability of each intervention will vary according to the details of the case 1. Treat with eye exercises 2. Correct/treat with refractive correction/modification 3. Correct with prisms 4. Treat with patching (occlusion) or penalisation 5. Refer for one of the above treatments by another practitioner 6. Refer for surgery 7. Refer for further investigation
What do I do?
When binocular vision anomalies require an intervention, there are several possible options. These are listed in Table 2. These options are not mutually
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• If the patient has vertical diplopia, then they can view from a distance of 1m, a 70cm horizontal wooden rod (a 50cm or 1m ruler can be used) • If the patient does not have vertical diplopia, then two Maddox rods can be used, placed in a trial frame with axes at 90˚, so that when the patient views a spotlight at a distance of 1-3m, they see two horizontal red lines Question 1: Move the wooden rod (or spotlight) up and down and ask: Where is the vertical diplopia (or separation of the red lines) greatest, in up gaze or down gaze? Question 2: In the position of maximum diplopia, are the two images parallel or torsional? • Up gaze: RSR, RIO, LSR, LIO • Down gaze: RIR, RSO, LIR, LSO
• Parallel: RSR, RIR, LSR, LIR • Torsional: RSO, RIO, LSO, LIO
• Right gaze: RSR, RIR Question 3: If parallel, does the separation increase on right or left gaze? • Left gaze: LSR, LIR Question 4: If tilted, does the illusion of • Up gaze: RIO, LIO (unlikely) • Down gaze: RSO, LSO tilt increase in up gaze or down gaze? Question 5: If tilted, then the two rods The arrow will point to the side with the paretic eye will resemble an arrow (< or >), or an X. If • Arrow points to the patient’s right: RSO, RIO they resemble an arrow, which way does • Arrow points to the patient’s left: LSO, LIO the arrow point? Question 6: If crossed, does the tilt angle increase in up gaze or down gaze? • Up gaze: bilateral IO paresis (very unlikely) • Down gaze: bilateral SO paresis
Procedure for Lindblom's method of differentially diagnosing cyclo-vertical incomitancies. The test instructions are given on the left and the paretic muscle indicated by a given answer is on the right full-threshold testing, so good practice with some incomitant deviations detected on motility testing would be to carry out further investigations to precisely quantify the anomaly. One very useful tool for this is the Thomson Software Solutions Hess Screen, which allows any optometrist with a Windows PC to carry out a Hess chart test. The cyclo-vertical incomitancies can be particularly difficult to diagnose, and various algorithmic approaches can be used. The best known of these is the Parks three-step test, but a recent approach5 is simpler and has been found by the author to be very useful (Table 3). associated with symptoms (Table 4, first row). Occasionally, heterophoria is encountered which may be decompensating, but the patient may avoid symptoms because they have foveal suppression. This condition is discussed elsewhere in this issue of OT6. These cases of decompensated heterophoria are an example of a condition which may worsen (become a strabismus), if left untreated (Table 1). Figure 1 is a simple model of binocular vision anomalies and is useful for considering what happens when patients develop fusional problems, and the approaches which might be appropriate for treatment. When the eyes are dissociated, most people will exhibit a dissociated deviation. Hopefully, during normal binocular fixation, the person can overcome this dissociated deviation to
Diagnosing decompensated heterophoria
Heterophoria is only a problem if it decompensates, and most cases of decompensated heterophoria are
A simple model of binocular vision (reproduced with permission from Evans, BJW (2002) Pickwell’s Binocular Vision Anomalies. Fourth edition. Butterworth-Heinemann)
COMPENSATED HETEROPHORIA OR DECOMPENSATED HETEROPHORIA OR STRABISMUS
render it compensated. Three factors influence how easy it is for a person to overcome their dissociated deviation. First, the size of the dissociated deviation is of some relevance; if it is very large, then it is likely to be harder for the person to overcome. A second factor is the force of motor fusion, which can be measured as the fusional reserves (Figure 1). A person with a heterophoria constantly exerts motor fusion to overcome their heterophoria, so their fusional reserves have to be adequate. Some conditions (e.g. illness, stress, old age) can cause the fusional reserves to deteriorate resulting in a previously compensated heterophoria decompensating. The third factor which influences how well a person can overcome their dissociated deviation is sensory fusion (Figure 1). This relates to the similarity of each eye’s image. For example, a person may have a compensated heterophoria until they develop a degraded image (e.g. from refractive error, cataract or pathology), when each eye’s image becomes less similar. This impairment of sensory fusion can cause heterophoria to decompensate. When a patient presents with a decompensating heterophoria or recent onset strabismus, then a consideration of Figure 1 will usually enable the cause of decompensation to be determined. If the dissociated deviation has changed, then the reason must be determined: a large change in dissociated deviation might be a sign of pathology (Table 5). If a non-pathological reason for decompensation can be found, then the alleviation of this could render a heterophoria compensated. One treatment might be to strengthen motor fusion by training the fusional reserves. In a case of anisometropia (which impairs sensory fusion), a treatment might be to prescribe contact lenses to equalise the retinal image size. The importance of sensory fusion explains why refractive corrections can be so important in the treatment of orthoptic anomalies. This is one reason why a full eye examination is essential for every orthoptic patient. It should include a refraction and all the other components of an eye examination which are appropriate for a patient of that age3. Table 4 has been designed to help with the diagnosis of horizontal decompensated heterophoria. The last two items are designed to detect binocular instability, which is a condition related to decompensated heterophoria3. For vertical heterophoria, if aligning prism of 0.5∆ or more is detected then, after checking trial frame alignment, measure the vertical dissociated phoria. If this is more than the aligning prism and there are symptoms then decompensated vertical heterophoria is a likely diagnosis.
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Professor Bruce JW Evans BSc (Hons), PhD, FCOptom, DipCLP DipOrth, FAAO ,
Treating decompensated heterophoria
All the interventions listed in Table 2 may be appropriate in some cases of decompensated heterophoria, however, it is very rare for this condition to require referral for surgery. The most suitable treatment for a given case depends on a number of factors, including type of decompensated heterophoria, age, motivation, intelligence, time available and, of course, the treatment preferences of the patient. Decompensated exophoria at near is often associated with convergence insufficiency and both these conditions are usually quite easy to treat with eye exercises (e.g. IFS exercises; Figure 2). But if a patient prefers, then base-in prisms can alleviate symptoms. These might be indicated in an older patient who is quite happy to have base-in prism in their reading spectacles, or in a younger patient who was about to have school examinations and wanted to postpone exercises until after their exams. A careful refraction is important; decompensated exophoria can be caused by the onset of myopia, in which case correction of the myopia might be the only necessary treatment. Even in emmetropic cases, refractive modification can be a very useful treatment for decompensated exophoria. For example, if an emmetropic eight year-old is prescribed -1.00DS, then this will cause accommodative convergence which may render an exophoria compensated. This treatment approach of refractive modification can also be very effective in cases of decompensated exophoria at distance, although these may need bifocals if the negative lenses cause problems at near. Esophoria should always cause the practitioner to suspect latent hypermetropia, and this is one of the indications for a cycloplegic refraction3. Even when no hypermetropia is found, refractive modification is usually very effective at treating near esophoria, where bifocals or varifocals can alleviate the symptoms. In any patient who is being treated by refractive modification, they are monitored every three months or so when, if possible, the refractive modification is reduced. Typically, the patient is prescribed the minimum refractive modification to eliminate any fixation disparity with the Mallett unit and to give good cover test recovery.
DISTANCE / NEAR
1. Does the patient have one or more of the symptoms of decompensated heterophoria
(headache, aching eyes, diplopia, blurred vision, distortions, reduced stereopsis, monocular comfort, If so, score +3 (+2 or +1 if borderline) sore eyes, general irritation)?
Are the symptoms at D K or N K All the following questions apply to D or N, as ticked (if both ticked, complete 2 worksheets) 2. Is the patient orthophoric on cover testing? Yes K or No K If no, score +1 3. Is the cover test recovery rapid and smooth? Yes K or No K If no, score +2 (+1 if borderline) 4. Is the Mallett Hz aligning prism: <1∆ for patients under 40, or <2∆ for pxs over 40? If no, score +2 Yes K or No K If a vertical aligning prism of 0.5∆ or more is detected, see note at bottom of page. ALL THE FOLLOWING QUESTIONS APPLY TO HORIZONTAL RESULTS 5. Is the Mallett aligning prism stable (Nonius strips stationary with any required prism)? Yes K or No K If no, score +1 6. Using the polarised letters binocular status test, is any foveal suppression < 4’? Yes K or No K If no, score +2
Add up score so far and enter in right hand column if score: < 4 diagnose normal, >5 treat, 4-5 continue down table adding to score so far
7. Sheard’s criterion: (a) measure the dissociated phoria (e.g., Maddox wing, prism cover test); record size & stability (b) measure the fusional reserve opposing the heterophoria (i.e., convergent, or base out, in exophoria). Record as blur/break/recovery in ∆. Is the blur point, or if no blur point the break point, [in (b)] at least twice the phoria [in (a)]? Yes K or No K If no, score +2 8. Percival’s criterion: measure the other fusional reserve and compare the two break points. Is the larger break point less than twice the smaller break point? Yes K or No K If no, score +1 9. When you measured the dissociated heterophoria, was the result stable, or unstable (varying over a range of ±2∆ or more). (e.g., during Maddox wing test, if the Hz phoria was 4∆ XOP and the arrow was moving from 2 to 6, then result unstable) If unstable, score +1 Stable K or Unstable K 10. Using the fusional reserve measurements, add the divergent break point to the convergent break point. Is the total (=fusional amplitude) at least 20∆? Yes K or No K If no, score +1
Add up total score (from both sections of table) and enter in right hand column. If total score: <6 then diagnose compensated heterophoria, if >5 diagnose decompensated heterophoria.
Scoring system illustrating the diagnosis of horizontal decompensated heterophoria and binocular instability (reproduced with permission from Evans BJW (2002) Pickwell’s Binocular Vision Anomalies. Fourth edition, Butterworth-Heinemann) the practitioner’s suspicions should be aroused by poor acuity in one eye from strabismic amblyopia. A checklist approach to the diagnosis of microtropia is provided in Chapter 16 of Evans (2002)3 and in Evans (2005)7. The first goal in the investigation of strabismus is to find its cause, and this is crucial in recent onset strabismus. Both comitant and incomitant deviations can result from pathology, so it is important to look for suspicious signs (Table 5). Three different aspects of strabismus require investigation. First, the motor deviation should be estimated (from the cover test movement) or ideally measured (e.g. by prism cover test or dissociation test). Second, the binocular sensory adaptation needs to be assessed. The most basic level of practice would be to record whether the patient has diplopia. If there
Institute Free-space Stereogram (IFS) exercises (reproduced with permission from IOO Sales)
Diagnosing and investigating strabismus
Strabismus occurs when the visual axes are misaligned and it is usually detected by cover testing. An exception to this is a certain type of microtropia, in which there is a small-angle strabismus and no movement may be seen on cover testing. These cases are difficult to diagnose, but
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Step Detect incomitancy
What to do
Any new or changing incomitancy • Carry out a careful motility test, including questions about diplopia • If the results are unclear, then carry out a cover test in peripheral gaze or ideally a requires prompt referral to a Hess screen test hospital ophthalmology unit • If there is a new or changing incomitancy, then refer Orbital pathology can cause strabismus, although this is rare Pathology which destroys or diminishes the vision in a significant part of the visual field of one eye can dissociate the eyes and cause strabismus • Is proptosis present? • Are the eye movements restricted? • Is there pain on eye movements? • Check pupil reactions, particularly looking for an afferent pupillary defect • Carry out careful ophthalmoscopy. In younger children, dilated fundoscopy might be necessary to obtain a good view, commonly after cycloplegic refraction. Keep checking ophthalmoscopy at regular intervals • As soon as the child is old enough, check visual fields • Carefully check pupil reactions and visual fields • Assess and record the optic disc appearance in both eyes • Monitor reports of general health (see text) • If a child has an esotropia, then look for hypermetropia • If an older patient is developing an exotropia, then have they always had an exophoria which is gradually decompensating with worsening cataract? • In every case, still look for pathology. But if you have found an obvious cause, then it is probably the cause • If you cannot find the reason why a deviation is increasing (e.g. child with accommodative esotropia starting to read more), then refer for a second opinion • If a strabismus does not respond to treatment (e.g. giving plus for hypermetropia), then review your diagnosis (e.g. accommodative esotropia) • Failure to respond to treatment might indicate a pathological cause, so refer for a second opinion
Look for orbital pathology Detect any ocular pathology
Look for neurological Pathology in the brain can cause problems comitant, as well as incomitant, deviations Look for obvious There is usually only one reason causes of the why a patient develops a strabismus strabismus. If you find a non-pathological cause, then the likelihood of there being pathology is greatly reduced Monitor the size of If the deviation is increasing the deviation then there must be a reason Is the strabismus If you think that you are responding to treating the cause of the treatment? strabismus (e.g. hypermetropia), then the situation should improve
Summary of some steps in determining if pathology is present in strabismus (reproduced with permission from Eye Essentials: Binocular Vision, Evans, 2005)
is a strabismus and no diplopia, then the patient has a binocular sensory adaptation. Good practice would be to determine what this adaptation is, and expert practice might involve measuring the depth of adaptation3. The third aspect of strabismus to be investigated is amblyopia. An attempt should always be made to measure monocular acuities, and ‘crowded’ acuity tests should be used at the earliest possible age. It would also be good practice to detect eccentric fixation by direct ophthalmoscopy.
The first two factors which need to be considered in the investigation of strabismus are the ages of the patient now and when the strabismus developed. Infrequently, the optometrist might see a child when strabismus has only recently developed. Typically, these will be esotropes of school age where there was an intermittent esotropia, which has recently become a constant esotropia. Whenever an esotropia is encountered, hypermetropia must always be suspected as the cause and in young children this is one of the indications for a cycloplegic refraction. If uncorrected hypermetropia is causing an esotropia, then the hypermetropia should be corrected.
If a child is found to have an intermittent strabismus, then early intervention is required to try to prevent the deviation from becoming constant. Similar investigations and treatments to those outlined in the section on heterophoria are warranted. People with constant strabismus who do not have diplopia must have one of the two diplopia avoiding mechanisms (sensory adaptations) – suppression or HARC. Orthoptic exercises are usually contra-indicated in these cases, because to treat either the sensory adaptation or the motor angle in isolation could cause intractable diplopia. One feature which does require treatment, if the patient is of the right age, is amblyopia. Strabismic amblyopia should not be treated over the age of about seven to 12 years. Between these ages, it should be treated very carefully, with regular monitoring of binocular status, because there is a slight risk of causing intractable diplopia. Generally speaking, patients should be treated as young as possible. Pre-school children are more difficult to treat and it is best for these cases to be managed by practitioners who have the appropriate expertise, experience, and equipment. These practitioners may be optometrists, but since many community optometrists
neither have a great deal of experience of these cases, nor the required visual acuity tests, most of them tend to be treated by hospital orthoptists or optometric practices which specialise in paediatrics. Children aged between five and seven years are commonly treated either in community optometric practices or in hospital eye departments. Whoever carries out the treatment will need to give the patient clear instructions about occlusion, monitor them closely, and carry out regular refractions to ensure that any spectacles are up to date. Full-time occlusion is usually best, so that a child who does not improve (e.g. after four to six weeks) can be referred for further investigations. Cases of amblyopia which are purely anisometropic (where no strabismus including microtropia is present) can be treated at older ages, certainly into their teen years and probably beyond3. These cases often improve with refractive correction alone, and contact lenses are ideal. Some cases also require patching. The main skills needed in the management of these patients are visual acuity measurement, accurate refractions, spectacle dispensing, contact lenses, and general optometric checks (e.g. ophthalmoscopy and visual fields) to rule out pathology. This means these patients can usually be cared for in primary eyecare (optometric) practices.
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Professor Bruce JW Evans BSc (Hons), PhD, FCOptom, DipCLP DipOrth, FAAO ,
How to specialise in orthoptics
Orthoptic investigation is a core component of every optometrist’s work, and all optometrists should be able to give basic orthoptic treatment (e.g. exercises for a convergence insufficiency or spectacles for a patient with an accommodative eso-deviation resulting simply from uncorrected hypermetropia). Practitioners who wish to increase their orthoptic expertise will find it easiest to take one step at a time. For example, explore the treatment of convergence insufficiency with exercises other than simple push-up (e.g. Figure 2). Then look for a case of decompensated exophoria at near and try these exercises on this patient. If patients are not suitable for exercises, then try refractive modification. Near eso-deviations which cannot be corrected by the full plus revealed by a cycloplegic may respond well to multifocals. Eye exercises for eso-deviations are harder work than for exo-deviations, but can also be effective with a suitably motivated patient. The treatment of non-strabismic anisometropic amblyopia is straightforward, as described earlier. As practitioners gain experience, increasingly challenging cases of strabismic amblyopia can be treated. If an amblyopic patient whose age makes them suitable for
treatment is seen by a practitioner who does not wish to treat them, then they will need to refer the patient to another practitioner. Orthoptics is an exciting area and optometrists who specialise find this both interesting and rewarding. Many CET courses on orthoptics (binocular vision anomalies) are available, and the COptom Diploma in Orthoptics provides a structured framework within which practitioners can increase their knowledge and skills in this field.
1. Millodot M (2000) Dictionary of Optometry. Fifth edition. Butterworth-Heinemann, Oxford. 2. Evans BJW (2004) The Diploma in Orthoptics. Part 1: A ‘how to’ guide. Optician 226; 5934: 26-27. 3. Evans BJW (2002) Pickwell’s Binocular Vision Anomalies. Fourth edition. Butterworth-Heinemann, Oxford. 4. Stevenson R (1999) Clinical practice survey 1998. College of Optometrists Newsletter 69: 7-10. 5. Lindblom B, Westheimer G and Hoyt WF (1997) Torsional diplopia and its perceptual consequences: a ‘user-friendly’ test for oblique eye muscle palsies. Neuro-Ophthalmology 18: 105-110. 6. Tang STW and Evans BJW (2005) The Near Mallett Unit Foveal Suppression Test. OT (Optometry Today/Optics Today) 45:1. 7. Evans BJW (2005) Eye Essentials: Binocular Vision. Butterworth Heinemann Health, Oxford.
About the author
Bruce Evans is Director of Research at the Institute of Optometry and is Visiting Professor to City University in London. He spends most of his working week seeing patients in a community optometric practice in Brentwood, Essex. He has written over 130 publications, including four textbooks on binocular vision anomalies. The exercises illustrated in Figure 2 can be obtained from IOO Sales (Telephone: 020-7378 0330 or visit www.ioosales.co.uk). This company exists to raise funds for the Institute of Optometry and pays a small ‘Award to inventors’ to the author based on sales of the exercises.
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