VISION THERAPY TECHNIQUES

AUTHOR

John McGann: Dublin Institute of Technology

PEER REVIEWER

Alvin Munsamy: University of KwaZulu-Natal

CHAPTER CONTENTS
INTRODUCTION ..................................................................................................................................................................... 1
TARGET SEPARATION AND VERGENCE DEMAND ........................................................................................................... 3
GUIDELINES FOR BV AND ACCOMMODATIVE THERAPY ................................................ Error! Bookmark not defined.
FEEDBACK MECHANISMS IN VISION THERAPY ............................................................................................................... 4
SUGGESTED READING ...................................................................................................................................................... 12

INTRODUCTION
Exercising convergence and accommodation to increase the flexibility in the relationship between the two systems can be
helpful for some people with decompensated heterophoria. Vision therapy techniques normally aim to do one of two
things:

 Maintain accommodation at the plane of regard and change the stimulus to the vergence system, or
 Maintain vergence in the plane of regard and change the stimulus to accommodate.

Most therapies in use rely on the former method, with accommodation maintained for a 40cm distance. Convergence
training brings the plane of convergence closer to the patient, while divergence training moves the plane of vergence
further away while maintaining the stimulus to accommodate. The greater the separation between the planes of vergence
and accommodation, the greater is the demand on the fusional vergence system. The practitioner could also use a
technique where the stimulus to accommodate is changed by adding plus or minus lenses, while maintaining the plane of
vergence constant (patient must maintain binocular single vision (BSV)). Again the level of difficulty is determined by the
distance between the planes of accommodation and vergence.

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Example: In a case where base out (BO) vergence was required to fuse a vectogram, how could
you make the task easier for a patient who was experiencing difficulty?

Answer: by bringing the two planes (vergence and accommodation) closer together the demand is
reduced  we could use base in (BI) prism or minus lenses in front of each eye.

Figure 8.1: Effect of negative powered lenses

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Figure 8.2: Effect of Base In Prism

TARGET SEPARATION AND VERGENCE DEMAND

One prism dioptre causes an image displacement of 1cm per metre.

In other words: 100cm/1cm = working distance/separation distance. This means that at a 40cm distance:

100cm/1cm = 40cm/ x cm
100 x = 40cm
x = 0.4cm
x = 4mm

This means that at a 40cm working distance we only need to know the target separation for similar points on the
vectogram or tranaglyph to calculate the vergence demand in prism dioptres.

Figure 8.3: Target Separation And Vergence Demand (a)

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Figure 8.4: Target Separation And Vergence Demand (b)

FEEDBACK MECHANISMS IN VISION THERAPY

 Diplopia
 Blur
 Suppression
 Lustre
 Kinaesthetic awareness
 SILO
 Float (part of SILO phenomenon)
 Localization
 Parallax

GETTING STARTED

The first thing to ensure is that the patient can appreciate physiological diplopia. It is suggested that the patient starts
with two pencils held vertically, in the median plane, against a plain background. The patient fixates first one pencil and
then the other pencil, allowing enough time to appreciate diplopia of the pencil that is not being fixated. The practitioner
should be satisfied that proper vergence changes occur when the patient changes fixation from one pencil to the other.
This is done by careful observation of the subjects’ eyes. When this exercise has been mastered, it should be easy for the
patient to demonstrate physiological diplopia in ‘normal’ situations. For example; fixating a finger and noticing the diplopia
of objects further away. This is a jump (phasic) exercise as well if the patient changes fixation from a near object to a
distant object (useful when treating CI). Jump convergence is believed to be very important in diagnosing CI as the near
point of convergence (NPC) test can appear normal initially if the subject makes an exceptional effort to ‘see the target
singly’ as it is moved closer. Daum (Am J Optom Physiol Opt. 1983) found that phasic rather than tonic (ramp) exercises
generally gave the best results.

BROCK STRING EXERCISE

One end of the string is attached to a door handle or similar object and the other end is held to the patient’s nose. Two
coloured beads are threaded onto the string to act as moveable fixation targets. When fixating either bead, the patient
should see both the string and the second bead in physiological diplopia, with intersection of the diplopic images
coinciding with the (fixated) bead. Where there is suppression and exophoria, part of the string will not be seen closer
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than fixation (Figure 10.5, right). Where there is suppression and esophoria, part of the string further than fixation will
be missing (Figure 10.5, left). By moving the bead along the string, suppression can be checked at all distances. With
practice, the patient can easily keep a check on whether or not an eye is suppressing even without moving the bead.

Figure 8.5: Brock string exercise

HOLMES/ ASHER LAW STEREOSCOPE

Two ‘orthophoria’ lines are seen from the focal point of each eyepiece lens to the midpoint between the lenses.
Stereoscope targets are placed so they lie on these lines and will be seen to coincide on the midline of the instrument.
Ignoring proximal convergence, the eyes will accommodate and converge according to their AC/A ratio.
 Increasing target separation divergence needed.
 Decreasing target separation  convergence needed.

NO requirement to change accommodation!

 Moving target away from eyes  convergence required

 Moving target towards eyes  divergence required

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Figure 8.6: Holmes/ Asher Law Stereoscope

 For Esophores, use targets of increasing separation (stimulate divergence) and/or move cards closer to eyes to
stimulate accommodation (exercise PRA).

 For Exophores, use targets of decreasing separation (stimulate convergence) and/or move cards further from
eyes to relax accommodation (exercise NRA).

BREWSTER STEREOSCOPE

This is designed to separate the fields of the two eyes using a septum. The optical system consists of a pair of +5.00DS
usually set at 95mm to induce base out prism. The target distance can vary from 20 cm(distance) to some closer
distances (reading distance). This is used in the middle or to the end of a vision training programme.

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Figure 8.7: Brewster Stereoscope

Various targets available:

 Create convergence and divergence therapy demand.

 Create jump vergence demand.
 Hand-eye coordination techniques.
 Accommodative training.
 Anti-suppression training.
 Present 1st, 2nd and 3rd degree fusion targets.

Accommodative Demand

A = (1÷TD) – P

A = accommodation (D)
TD = distance between target and lens plane (m)
P = power of stereoscope lenses (D)

Convergence Demand

C = (P x LS) – (TS÷TD)

C = vergence demand in Δ
P = power of stereoscope lenses
LS = Separation of optical centres of stereoscope lenses (cm)
TD = distance between target and lens plane (m)
TS = distance between corresponding points of the stereogram (cm)
 +value  conv. demand
 - value  div. demand

VARIABLE VECTOGRAMS AND TRANAGLYPHS

The patient wears polarised or Red/Green glasses. Targets are cross polarised (vectograms) of different colours e.g.
Red/Green. Move the right eye target to the left to exercise PFR or to the right to exercise NFR. Clinically there are
differences between vectograms and tranaglyphs. The Red/Green can present obstacle to fusion for some people,
especially where there is moderate suppression and accommodative problems.

Viewing the Bernell Chicago Skyline Vectogram (Figure 8.8), the patient can alternate between convergence and
divergence by looking from plane to the buildings.

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Image reproduced with permission of Bernell Corporation.

Figure 8.8: Bernell Chicago Skyline Vectogram

BERNELL QUOITS

The Bernell Quoits allows both convergence and divergence to be trained. It is useful in training jump convergence by
alternately concentrating on the Quoit target and then fixating a second (distance) target through the centre.

Figure 8.9 : Bernell quoits

FREE-SPACE FUSION TECHNIQUES

Examples include Lifesaver cards, Eccentric circles and Free-space fusion cards A. The concept is the same as for the
Aperture Rule, i.e. chiastopic or orthopic fusion technique. For convergence exercises they can prove to be more difficult
for the patient than even the Aperture Rule trainer. However, some people find them easier for divergence training. The
difference between Eccentric circles and Free-space fusion cards B is that there are increasing, stepped (phasic)
vergence demands in the latter and variable (tonic) demands in the former.

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LIFESAVER CARDS

Figure 8.10: Lifesaver cards

INSTITUTE FREE SPACE FUSION CARDS

This was developed by Prof. Bruce Evans and is inexpensive. It is suitable for home use (parental supervision as
required). There are detailed instructions for practitioner and patient. If symptoms persist, or if diplopia or blurred vision
occurs, stop. Ensure suppression checks. Use for 10-20 min per day for 3 to 4 weeks and review.

IFS (Card 1)

It introduces the concept of physiological diplopia. Initially 2 dots are used, with the patient over-converging on a pencil
held between the eyes and the page. They should see 4 dots, and by moving the page should fuse the 2 innermost dots.
Next the patient moves on to a similar exercise, this time using rings. They should experience depth perception. The
target separations on this page are small so the amount of over-convergence is limited. There is a self-test question at
this point which checks that the direction of depth perception is in the correct direction.

IFS (Card 2)

Here there is significant target separation and the addition of shapes to the normal ‘ring targets’. NRA is exercised by the
practitioner stressing the importance of keeping the targets clear. Any suppression present should be reduced by the
patient’s awareness of physiological diplopia and stereopsis.

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Institute Free Space Card 2

Figure 8.11: Institute Free Space Card 2

Foveal suppression is specifically treated by the patient viewing an eight-limbed star at the centre of the targets. Parts of
the star are seen by the right eye and parts by the left eye. To see all eight limbs, there must be no suppression. Target
separation increases as the patient progresses down the page. Initially the patient is asked to move gaze from one set of
targets to the next (STEP exercise). Next they are required to move the page closer to their face (RAMP exercise).

IFS (Cards 3 and 4)

Card 3 uses an A4-sized Autostereogram. The patient must use PRC to get a stereo view and then use NRA to obtain a
clear image. If viewed correctly, the patient sees a series of steps rising towards them, with a letter on each step. As they
progress form one step to the next (higher) one the convergence requirement increases. Card 4 uses a similar
autostereogram to card 3.

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Autostereogram used on IFS Card 3

Figure 8.12: Autostereogram

Autostereograms were invented by Tyler & Clarke in 1979. They consist of repetitive stereograms so the viewer can fuse
any two images in the series and perceive depth. Try to converge on a finger held close in front of this image. What do
you see?

USES OF THE IFS SERIES

This is used to train convergence in cases of decompensated XOP at near, convergence insufficiency, decompensated
basic XOP, intermittent near XOT and constant near XOT (Evans, 2002). It can be photocopied onto overhead projector
transparencies to train divergence in cases of SOP. Evans recommends that the cards be used on patients over the age
of 10yrs.

BERNELL APERTURE RULE

This is a more difficult technique than the variable vectograms and tranaglyphs in that there is a measurable demand on
the vergence system from the start (depending on the image separation on the card).

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Figure 8.13: Bernell Aperture Rule

In other techniques the vergence demand can be set at zero initially to ease the patient in gently. Due to this, it is usual to
wait until later in the vision therapy programme before introducing the Aperture Rule. A single aperture is used to train
convergence whereas a double aperture is used to train divergence. Either the patient fuses by converging in front of the
plane of accommodation (chiastopic fusion) or behind the plane of accommodation (orthopic fusion). There are 12
cards with varying vergence demands from 2.5∆ (card 1) to 30∆ (card 12). A single aperture is used for convergence
(base out) training and double aperture for divergence (base in). Aperture represents the plane of vergence and the cards
represent the plane of accommodation. There is a pointer supplied to aid initial fusion. Accommodative flippers can be
used to increase the level of difficulty.

SUGGESTED READING

1. Pickwell’s Binocular Vision Anomalies, 2002; Butterworth Heinemann; Chapter 10

2. Clinical Management of Binocular Vision; Scheiman & Wick; 2002; Lippincott Williams & Wilkins; Chapter 5.
3. Criteria for prescribing optometric interventions;OPO:2003 23:429-439
4. Foundations of Binocular Vision: A clinical Perspective; Steinman, Steinman & Garzia; McGraw-Hill; 2000; Chapters
2&7

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