British Orthoptic Journal 2002

Editorial: Stance on duplicate and salami publication

Alison Y Firth

Preferential looking and grating acuity in the assessment of

vision
Sarah J Shea

Abstract
Aim: This review considers the value of preferential looking and grating
acuity in the clinical assessment of infant visual acuity.
Methods: A literature review was conducted to identify articles relevant to the
development of preferential looking and its progression from laboratory
to clinical tool. Articles that considered the clinical value of preferential
looking and grating acuity in the detection of visual disorders were also
reviewed and comparisons made with other clinical tests of visual
function. Special emphasis was given to acuity assessment in
amblyopia.
Results: Procedural variations can have significant effects on acuity estimation
and highlight the need for a high degree of objectivity when using
preferential looking. More complex visual stimuli yield a more precise
estimate of acuity than a grating stimulus, particularly in cases of
amblyopia associated with strabismus, but grating acuity should not be
dismissed in the evaluation of infant acuity.
Conclusions: Whilst they have limitations, preferential looking and grating acuity are
of value in the assessment of infant visual acuity. Within a clinical
department a standardised preferential looking methodology with a
strict threshold criterion is essential. In addition there is a need to
evaluate fully the nature of the vision loss as opposed to dismissing an
acuity value or test as defective.

The effect of ageing on eye movement: a literature review

Jillian H Davidson and Paul C Knox

Abstract
Aims: To present a review of the literature on the effect of ageing on the eye,
the neuroanatomical structures controlling eye movement and their
consequent behavioural effects, from both clinical and quantitative
perspectives.
Methods: We examined the literature on the effects of ageing on different types
of eye movement, including the clinical presentation of restrictions in
ocular motility with age. As many areas of the brain play a role in the
control and co-ordination of eye movement, literature on how ageing
affects these structures was examined and we sought to relate
structure and function.
Results: Brainstem oculomotor structures are remarkably well preserved into
old age. However, age-related effects on the cerebral cortex lead to
older subjects exhibiting problems with a number of oculomotor tasks.
Clinically, decreases in the range of movement are observed in the
absence of pathology, particularly in upgaze.
Conclusions: The development of restrictions in eye movement with age need to be
considered when examining older patients. Asymmetries remain a
useful indicator of pathology. The observation that brainstem
structures are preserved while oculomotor behaviour is modified in
ageing, suggests that oculomotor tasks may be useful for probing the
effects of ageing on structures above the level of the brainstem.

Diagnostic, aetiological and management considerations in

accommodative insufficiency
Veronica S Henshall and Fiona J Rowe

Abstract
Aims: To review the diagnosis, differential diagnosis, aetiologies and clinical
management of accommodative insufficiency.
Methods: A literature review was undertaken to address these aspects of
accommodative insufficiency.
Results: Accommodative insufficiency typically presents with a remote near
point of accommodation and a reduction in the accommodative
amplitude, and may be associated with a secondary convergence
insufficiency. Differential diagnosis must be made with convergence,
accommodative and refractive anomalies, and once accommodative
insufficiency is confirmed the management includes prescription of
plus lenses and accommodative training.
Conclusions: Clinically it appears that young women with accommodative anomalies
are seen more frequently than men and further research into this area
is planned.

Aniseikonia and its effect on binocular function: a review

Catherine Stewart and Jon Whittle

Abstract
Aims: To describe the concepts underlying aniseikonia and discuss
management and management techniques.
Methods: A literature review was conducted to identify articles relevant to
aniseikonia with particular focus on anisometropia, aniseikonia and
binocular vision.
Results: Aniseikonia is an apparent inequality in the size of the images seen
with each eye. The symptoms of aniseikonia range from mild
distortions of visual space, through to headaches, asthenopia and
disruption of binocular vision. Aniseikonia most commonly occurs in
patients with corrected anisometropia, and since the introduction of
intraocular lens implants a new population with the potential for
aniseikonia has been formed. The most accurate method for
measuring aniseikonia, the space eikonometer, is not readily available.
However, aniseikonia may be estimated and graded using modified
clinical techniques.
Conclusions: The visual system is normally able to cope with 2-3% of aniseikonia
but any more than this is likely to produce symptoms and reduced
binocular functions. Anisiekonia is managed by prescribing contact
lenses instead of spectacles or by manipulating spectacle lens
parameters to reduce image size differences.

Reduced adduction following lateral transposition of the

vertical rectus muscles for sixth nerve palsy
Helen Murgatroyd, Irene Fleming and Caroline MacEwen

Abstract
Aims: To discuss the role, indications and limitations of lateral transposition
of the vertical rectus muscles for the management of lateral rectus
palsy.
Methods: We retrospectively reviewed the clinical notes of 6 patients undergoing
this surgery, and discuss the results in the context of the current
literature.
Results: All the patients were operated on by the same surgeon. One patient
had a partial bilateral sixth nerve palsy, 5 patients had unilateral
complete palsy. All patients had had pre-operative botulinum toxin, 4
of whom had had two separate doses. Post-operatively, 3 patients
had an exodeviation for near, 2 of whom had previously undergone
surgery to the medial rectus. All the patients had documented mild to
moderate weakness of adduction in the operated eye.
Conclusions: The lateral transposition of the vertical rectus muscles can improve the
size and location of binocular single vision in patients with complete
unilateral or bilateral partial lateral rectus palsy. The surgery will not
allow full ocular rotation; reduced abduction and reduced adduction is
to be anticipated.
The effect of Fresnel prisms on binocular vision
Elaine S Moreland and Helen J Griffiths

Abstract
Aims: The detrimental effect of Fresnel prisms on visual acuity has been well
documented, whilst their effect on binocularity is less clear. The aims
of this study were to assess the effect of Fresnel prisms on motor
fusion and stereo-acuity and to compare the results of Fresnel prisms
placed over one eye with the equivalent strength split between both
eyes.
Methods: Fifteen participants (mean age 25.7 ± 7.7 years) with normal binocular
single vision and minimum corrected Snellen visual acuity of 6/6 were
recruited. The effect on motor fusion and stereo-acuity of Fresnel
prisms of various prism strengths placed over one eye or split between
the two eyes was assessed using a stereoscope.
Results: The deterioration in binocular functions was increasingly evident as
prism strength increased and found to be significantly greater when
single prisms were used.
Conclusions: Fresnel prisms have been found to impair binocular functions, the
effects being significantly greater when a single prism is placed over
one eye compared with the equivalent strength split between the eyes.
It is suggested that when using Fresnel prisms of greater than 10
prism dioptres a trial with the required prismatic power split between
the eyes is undertaken. This may increase the chance of diagnosing
potential binocular single vision in functional cases and if used
therapeutically may improve the patient's visual comfort.

Is there a relationship between prism fusion range and

vergence facility?
Anna C Melville and Alison Y Firth

Abstract
Aim: To investigate the relationship between prism fusion range (PFR) and
vergence facility (VF) measurements in subjects with normal binocular
vision.
Methods: Twenty-eight subjects (mean age 19 ± 1 years) with normal binocular
single vision (BSV) underwent measurement of the PFR and VF in a
varied order, at a test distance of 1/3 m. The PFR measurements
recorded were the base out (BO) range to blur and break point and
base in (BI) range to break point. The total PFR was calculated. The
VF was assessed over a 1 min time period using a 12 prism dioptre
BO /3 prism dioptre BI flip prism and recorded in cycles per minute
(cpm).
Results: No correlation was demonstrable between any of the single measures
of the PFR and the VF results. The BO PFR to break point and the BI
PFR results obtained (means 46 prism dioptres BO and 14 prism
dioptres BI) were not significantly different from quoted 'normal'
 values. The VF results obtained (mean 12 ± 4.2 cpm) were found to
be significantly different from the reported mean value.
Conclusion: In a group of young adults with normal BSV, no correlation between
PFR and VF was found. The two tests may quantify different aspects
of vergence or, alternatively, results of one or both tests in this study
may be unreliable.

The relationship between the strength of sensory fusion and

motor fusion amplitude
Gemma E Hocking and Joanne E Gage

Abstract
Aims: To determine the strength of sensory fusion in a normal population at
1/3 m and 6 m testing distances, and to investigate whether a
correlation exists between the strength of sensory fusion and motor
fusion amplitude.
Methods: The presence and strength of binocular single vision was investigated
in 36 participants at 1/3 m and 6 m. The Sbisa bar was used to test
the strength of sensory fusion and Gulden prism bars were used to
test motor fusion amplitude.
Results: The strength of sensory fusion at 1/3 m was found to be 11.01 filters ±
3.37 and at 6 m was found to be 11.25 filters ± 3.06. There was no
significant correlation between the strength of sensory fusion and
motor fusion amplitude at 1/3 m or 6 m (p>0.05). There was no
significant correlation between the strength of sensory fusion at 1/3 m
and 6 m (p>0.05). Correlation between motor fusion amplitude at 1/3
m and 6 m was statistically significantly (p<0.0001).
Conclusion: Despite being two components of fusion, sensory and motor fusion
were not found to correlate. No statistically significant difference was
found in the strength of sensory fusion at 1/3 m and 6 m. This
suggests that, in subjects with normal binocular single vision, the
strength of sensory fusion need be tested at only one distance.

Detection of glaucoma: the role of visual fields

Gillian E Coyle, John D Ellis and Caroline J MacEwan

Abstract
Aim: To evaluate the effectiveness of visual field testing performed by
optometrists in the community for the detection of glaucoma.
Methods: Case records were reviewed on all patients with visual field
assessment by community optometrists as part of their referral criteria.
The total number of patients included was 87. Referrals were divided
into four categories: subgroup 1, visual field defect + raised
intraocular pressure (IOP) + pathological disc cupping; subgroup 2,
 visual field defect + pathological disc cupping; subgroup 3, visual field
defect + raised IOP; subgroup 4, visual field defect alone. Each
patient attending the hospital eye service had visual fields plotted with
the Humphrey automated perimeter using the Central 24-2 Fastpac
programme. Full ophthalmological examination followed over a
number of visits and the diagnosis of glaucoma was confirmed or
excluded.
Results: The positive predictive value (PPV) for the diagnosis of glaucoma for
each patient subgroup was as follows: subgroup 1, 75%; subgroup 2,
63%; subgroup 3, 25%; and subgroup 4, 0.
Conclusions: This study demonstrates that patients suspected of having glaucoma
who are referred to the hospital eye service with a suspected visual
field defect are highly unlikely to be subsequently confirmed to have
glaucoma unless the defect is accompanied by other disease
indicators, in particular pathological disc cupping.

Use of log MAR charts for the measurement of visual acuity in

Orthoptic departments throughout the UK
Catherine Stewart

Abstract
Aim: To establish the dissemination of logMAR testing of visual acuity in
Orthoptic departments throughout the UK, and to establish the main
reasons given for not using logMAR tests.
Methods: This questionnaire-based study audited current usage of logMAR
visual acuity testing in Orthoptic departments throughout the UK.
Questionnaires were sent to all BOS members, but results were
analysed per department.
Results: One hundred and six of 288 orthoptic departments returned the
questionnaire (37%). Of these departments only 21% are currently
using logMAR tests. Departments not using logMAR-based tests were
not doing so due to insufficient understanding of logMAR tests (64
departments, 73%), insufficient funds (45 departments, 51%), Snellen
tests providing adequate visual acuity measurements (38
departments, 43%), other health professionals being reluctant to
change (32 departments, 36%), test charts being too bulky (19
departments, 21%) and other reasons (5 departments, 6%).
Conclusions: The majority of departments not using logMAR tests acknowledge that
these tests have potential benefits for improving visual acuity testing.
The major issues which need to be overcome are that health
professionals have insufficient understanding and information provided
on logMAR tests, in addition to insufficient funds at present to change
acuity tests throughout their eye department.
Concomitant esotropia following sixth cranial nerve palsy
Fiona J Rowe and Carmel P Noonan

Abstract
Aim: To discuss the aetiological and recovery aspects of two cases of sixth
nerve palsy onset in older children.
Methods: We present two cases of sixth nerve palsy onset at age 11 years in
patients with previously documented binocular vision but who
subsequently developed concomitant esotropia and suppression.
Results: At such an age the visual system is considered to have reached a
mature level and maintenance of binocular vision would be the
expected sensory outcome in these children. Literature reports of
adults with acquired suppression responses or with the ability to
'ignore' diplopia implicate a degree of plasticity in the mature visual
system.
Conclusions: Risk factors associated with such poor sensory outcome may include
loss of visual function (acuity and field).

A case of intraorbital injury

Marion Logan

Abstract
Aims: To report the risk of orbital cellulitis following intraorbital trauma and to
highlight the difficulty of diagnosing foreign bodies with CT scanning.
Methods: A case is discussed of an 8-year-old girl who presented with orbital
cellulitis after sustaining a facial injury whilst playing. It was
discovered after CT scanning and examination under anaesthetic that
an intraorbital foreign body was the cause. Once the foreign body was
removed she was left with residual restriction of movement and
diplopia.
Results: The patient recovered well and regained excellent binocular single
vision. She was left with only a slight residual weakness of depression
in the affected eye.
Conclusions: Urgent investigation and treatment of orbital cellulitis is crucial to
prevent loss of sight.

A case of Moebius syndrome with vertical muscle

involvement, not well recognised by the literature
Gemma C I Bates

Abstract
Aims: To present a case of Moebius syndrome with unusual ocular motility
and compare it with the relevant literature.
Methods: Documentation of the case in relation to its history, Orthoptic
assessment and photographic illustrations is presented.
Results: Limitation of elevation of the right eye was present and this unusual
feature of the syndrome is compared with similar published cases.
Conclusions: Moebius syndrome has been recognised as a multi-system disorder of
VIth and VIIth nerve involvement and variable associated features.
The case presented shows a complex of ocular motor abnormalities
with unusual vertical involvement of limited elevation that highlights the
variability of the syndrome.

Spasmus nutans: a case review

Sarah E Ashurst

Abstract
Aims: To describe a case of spasmus nutans and to comment on the
implications of the condition.
Methods: A 7-month-old female who presented with a large angle esotropia,
titubation, torticollis, and nystagmus on attempted convergence is
discussed. After a full ophthalmic and neurological review, the
diagnosis of spasmus nutans was confirmed.
Results: CT scan and ultrasound results were normal. Spasmus nutans was
still demonstrable at the age of 11 months.
Conclusions: The clinical presentation of spasmus nutans can vary a great deal, and
some form of neuroimaging is advocated to eliminate the possibility of
any anterior visual pathway abnormality.

Isolated abducens nerve palsy without diplopia occurring in

ophthalmoplegic migraine
Gail Horne, Ronnie Bhola and Sundeep Kheterpal

Abstract:
Aim: To present a case of ophthalmoplegic migraine with recurring lateral
rectus palsy in a child.
Method: Details are reported of a young girl who was examined several times
over a 9 year period. During this time she was found to demonstrate a
variable degree of esotropia and lateral rectus underaction which
increased significantly after a migraine attack.
Results: No other abnormal neurological signs were found on investigation and
the deviation became permanent with suppression due to the early
onset of the condition. The aetiology was presumed to be
ophthalmoplegic migraine.
Conclusion: Ophthalmoplegic migraine was diagnosed following exclusion of other
causes. Repeated episodes led to a constant esotropia with
permanent loss of lateral rectus function and suppression.