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Management options for adult binocular vision disorders: part 2: heterophoria.

Binocular vision anomalies are commonly encountered in optometric practice. In adult patients, we need to differentiate between the asymptomatic and symptomatic heterophorias which may require management, for which there are a variety of approaches available depending on the diagnosis. This VRICS tests practitioners' knowledge of identifying, investigating and managing adult heterotropia conditions.

Course code C-30660 | Deadline: May 31, 2013

Learning objectives

Assess binocular status using objective and subjective means in adult patients with heterophoria (Group 8.1.1)

Manages adult patients with heterophoria including interpretation of test results and considering treatment options such as exercises and refractive correction (Group 8.1.3)

Readers are encouraged to discuss the cases in this FREE VRICS with their colleagues, conduct simple Internet searches, and use the references provided to complete the Multiple Choice Questions (MCQs). Please note that there is only one correct answer for each MCQ. Complete the VRICS test online at: www.optometry.co.uk/cet/exams

MORE INFORMATION

* EXAM QUESTIONS Under the new enhanced CET rules of the GOC, answers to MCQs for this exam must be submitted online. Please visit www.optometry.co.uk/cet/exams and complete by midnight on May 31, 2013. You will be unable to submit exams after this date. Answers will be published on www.optometry.co.uk/cet/exam-archive and CET points will be uploaded to the GOC on June 10, 2013. You will then need to log into your CET portfolio by clicking on "MyGOC" on the GOC website (www.optical.org) to confirm your points.

* REFLECTIVE LEARNING Having completed this CET exam, consider whether you feel more confident in your clinical skills---how will you change the way you practice? How will you use this information to improve your work for patient benefit?

[A]

Man, aged 74

RE      +0.75   -0.75   110    6/9-
LE      +1.75   -0.50    95    6/6+

DV CT   3[DELTA]  R/L 2[DELTA]  exophoria
NV CT   6[DELTA]  R/L 8[DELTA]  exophoria

Near vertical fusional reserve x/6/4

Intermittent diplopia for a few weeks,
covers one eye to read


[01] Which of the following statements is CORRECT regarding the test being performed in Image A?

a The patient should be asked to report the first blurring of a target

b Diplopia with more than 3A of vertical prism is a normal result

c An alternating cover test should be performed

d A single vertical line of letters is the most appropriate fixation target

[02] What is the MOST likely cause of the symptoms for the patient with the clinical data shown in Image A?

a Decompensation of a longstanding incomitancy

b Monocular diplopia caused by cataract

c Acquired Brown's syndrome

d Recent onset IIIrd nerve palsy

[03] Which management option would be MOST appropriate for the patient with the clinical data shown in Image A?

a Urgent referral to be seen by a neurologist

b Chavasse lens in the right eye of the reading spectacles

c Soon referral to be seen by an orthoptist

d Vertical and horizontal prism in the reading spectacles

Reference to aid completion of the case

Weddell L (2010) Investigative techniques in binocular vision. Optometry Today 50 (November 26): 37-45. (www.optometry.co.uk/ uploads/articles/nov-26-2010-cet.pdf)

[B]

Woman, aged 22

RE      +0.25   -0.50   180   6/5
LE      +0.50   -0.25   10    6/5

DV CT   Ortho
NV CT   5[DELTA] esophoria

New job in factory, works at 25cm

Eyestrain and frontal HA later in day


[04] Which of the following statements is CORRECT regarding the test being performed in Image B?

a The images of the two eyes are dissimilar so cannot be fused

b A 6[DELTA] base up prism dissociates the eyes

c Tangent scales can be used at any near working distance

d Coloured filters would be used to dissociate the eyes

[05] Which statement BEST describes the results of the test shown in Image B?

a There is convergence insufficiency

b The gradient AC/A ratio is 6[DELTA] per dioptre

c The heterophoria at 33cm is 15[DELTA] esophoria

d The patient is unable to accommodate by 5D

[06] Which management option would be MOST appropriate for the patient shown in Image B?

a Exercises to improve positive fusional reserves

b 3[DELTA] base out prism, split between the eyes

c Pencil push up exercises

d Spectacles with low positive power to eliminate fixation disparity at near

[C]

Man, aged 51

RE      Plano     -      -    6/5
LE      +0.50   -0.25   85    6/5

Near add +1.25 for 38cm

DV CT   3[DELTA] exophoria
NV CT   10[DELTA] exophoria

Near fixation disparity 2.5 [DELTA]     IN to align
Intermittent diplopia at near with new reading
spectacles


[07] What is the MOST likely cause of the symptoms for the patient with the clinical data shown in Image C?

a Acquired lateral rectus palsy

b V-pattern exophoria

c Base out prism induced by too wide optical centration of the reading spectacles

d Decreased accommodative convergence when using the reading spectacles

[08] Which of the following statements about the management of the patient with the clinical data shown in Image C is MOST appropriate?

a The patient is likely to have prism adapted following a change in fixation disparity after viewing through a prism

b Vision training will not work for this patient as he is presbyopic

c The reading addition should be increased to +2.00DS

d The optical centration of the reading spectacles should be decreased by 10mm from the near PD to reduce the fixation disparity

[09] Which of the following statements about the exercise shown in Image C is TRUE?

a The direction of the stereoscopic effect shows whether the patient is under or over-converging

b It can be used in the presence of suppression

c It exercises and improves the base in fusional reserves

d The increasing image separation requires decreasing over-convergence

Reference to aid completion of the case

Evans BJW (2007) Binocular vision anomalies: Part 1 symptomatic heterophoria. Optometry Today 47 (March 9): 38-47. (www.optometry.co.uk/uploads/articles/CET9-03%20web.pdf)

[D]

Woman, aged 19

RE      -3.75   -1.00   10    6/5
LE      -4.25   -1.50   165   6/5

DV CT   3[DELTA] exophoria
NV CT   3[DELTA] exophoria @ 40cm

Near point of convergence 18cm

Intermittent diplopia and frontal HA when
studying


[10] Which of the following is NOT associated with the condition shown in Image D?

a A near point of convergence of more than 10cm

b Accommodative insufficiency

c Near heterophoria greater than distance heterophoria

d Divergence excess exophoria

[11] Which of the following statements about the exercise shown in Image D is TRUE

a Diplopia of the far target will be more noticeable when it is closer to the near target

b Physiological diplopia of the farther target acts as a suppression check

c If diplopia of the near target is noted, the exercise should be stopped

d The exercise should be performed monocularly

[12] Which statement regarding the treatment of the patient with the clinical data shown in image D is CORRECT?

a Symptoms should resolve within four weeks of treatment

b Positive fusional reserves and near point of convergence should be improved

c Base-in prism would be effective

d Practice-based vision therapy is less effective than home pencil push-ups

References to aid completion of the case

1. Evans BJW (2007) Binocular vision anomalies: Part 1 symptomatic heterophoria. Optometry Today 47 (March 9): 38-7. (www.optometry.co.uk/uploads/articles/CET9-03%20web.pdf).

2. Scheimann M et al. (2005) A Randomized Clinical Trial of Vision Therapy/Orthoptics versus Pencil Pushups for the Treatment of Convergence Insufficiency in Young Adults. Optometry & Vision Science 82:E583-E595. http://jpk.tjtc.edu.cn/07/yanjing/downshuangyuyuandi/8.%20 A%20Randomized%20Clinical%20Trial%20of%20Vision%20TherapyOrthoptics%20 versus%20Pencil%20Pushups%20for%20theTreatment%20of%20Convergence%20 Insufficiency%20inYoung%20Adults.pdf

Dr Sheila Rae graduated from UMIST in ophthalmic optics and spent several years in clinical practice before completing a PhD at Anglia Ruskin University, Cambridge, in 2007. Following this, she was appointed senior lecturer in the Department of Vision and Hearing Sciences at Anglia Ruskin. She holds a College Higher Diploma in Orthoptics and teaches both optometry and ophthalmic dispensing students. Her research interests are myopia, wavefront aberrations, contact lenses and clinical visual function. She is an examiner and assessor for the College of Optometrists, a member of the British Standards Institute Committee for Ophthalmic Instrumentation and a fellow of the British Contact Lens Association and the Higher Education Academy.
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Title Annotation:VRICS: 1 CET POINT
Author:Rae, Sheila
Publication:Optometry Today
Geographic Code:4EUUK
Date:Apr 19, 2013
Words:1427
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