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MODULE 10:3 • COURSE CODE: C-5196

Binocular vision anomalies: Part 1

Symptomatic heterophoria
Bruce Evans
38 This article will concentrate on ways in which optometrists can enhance
visual function in patients who may have symptomatic yet non-strabismic
binocular vision anomalies. The most common ocular motor status is
9/03/07 CET

heterophoria, and the largest section of this article will deal with this
condition. Heterophoria is normal, and only infrequently requires treatment.
Patients who require treatment will usually have symptoms, and so are
particularly likely to consult optometrists. Convergence insufficiency is a
fairly common cause of symptoms in primary care optometric practice. The
treatment of this condition is usually straightforward and will be described.
The diagnosis and treatment of accommodative problems also will be
discussed. Dyslexia is the most common specific learning difficulty and
affects about 5% of the population. Although dyslexia is not usually caused
by visual anomalies, certain visual problems are more likely to be present in
dyslexia than in good readers and the diagnosis and treatment of these
visual correlates will also be discussed.

Heterophoria fusion of each monocular image into a fusional reserves, which bring about
single percept (fusional vergence). motor fusion. For example, a child
Overview When an eye is covered, for example may have a fever, or sometimes even
If a person is placed in a completely during a cover test, there is no fusional stress or tiredness, which can cause
dark environment, then the visual vergence and the eye behind the cover the fusional reserves to be reduced.
system has no feedback that can be is likely to revert towards the resting Second, there may be a problem with
used to control ocular alignment. The position. This is why, on average, the sensory fusion. The process of sensory
eyes are free to remain aligned or to normal heterophoria is a small degree fusion requires each monocular image
deviate, and in most cases they deviate. of esophoria for distance vision and to be clear and similar to one another.
In terms of vergence, the eyes move to exophoria for near vision (Figure 1). A Problems that can interfere with
their resting position in which the normal, healthy, visual system is sensory fusion include anisometropia,
vergence angle is aligned for a distance usually able to overcome these cataract, or metamorphopsia from a
of about one metre. Conceptually, if the heterophorias without any difficulty: macular lesion.
resting position of the vergence system the heterophoria is compensated. The third reason why a patient may
is with the eyes aligned for a distance Optometrists become interested in be unable to compensate for their
of about one metre, then distance heterophoria in cases where the patient heterophoria is if the heterophoria is
vision can be thought of as divergence is not able to fully compensate for the unusually large. For example, there
away from this resting position and heterophoria: it becomes may be an anatomical reason why the
near vision as convergence away from decompensated. Figure 2 schematically resting position of the eyes is very
this resting position (Figure 1). illustrates the factors which normally different to the average described
Vergence is influenced by several cause a heterophoria to be above, where the eyes are
factors, including an awareness of the compensated, and there is therefore approximately aligned at a distance of
distance of the object (proximal usually one (or more) of three reasons 1m. Another reason for an atypical
vergence), cross-linking with the for a heterophoria becoming heterophoria is the effect of
accommodative system decompensated. First, there may be an accommodative vergence, for example
(accommodative vergence) and the fine inadequacy of the vergence system. in uncorrected high hypermetropia.
tuning of ocular alignment during the The vergence system manifests as the This approach, of using the

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difficulty changing focus); asthenopia

(headaches, aching eyes, sore eyes); or
referred problems (general irritation).
The difficulty is that most of these
symptoms are non-specific: they could
be caused by problems other than
decompensated heterophoria. This
means that there is a need for clinical
testing of patients with these
symptoms: the practitioner must detect 39
signs as well as symptoms. < Figure 2
There are also two occasions when A simple model of binocular vision.

9/03/07 CET
patients with a decompensated Reproduced with permission from Evans,
heterophoria might not report B.J.W. (2002) Pickwell’s Binocular Vision
symptoms. Some patients, typically Anomalies, 4th edition, Elsevier
young ones, may not recognise their
symptoms until they have been
corrected: a child may have always
< Figure 1 had blurred vision when reading and Mallett unit fixation disparity test
Schematic illustration of resting so feels that this is normal. A second It is probably true to say that the
position of vergence system,
reason is that occasionally patients Mallett unit fixation disparity test has
divergence, and convergence
with decompensated heterophoria may revolutionised the diagnosis of
develop a compensatory strategy to decompensated heterophoria in
avoid symptoms: foveal suppression. primary eyecare in the UK. The test
information in Figure 2 to determine detects fixation disparity and measures
what factor(s) have caused a Cover test the aligning prism or aligning sphere:
heterophoria to decompensate, is not The cover test can provide a great deal the prism or sphere that eliminates the
just academic. When an optometrist of information. It can be used to fixation disparity.
encounters a patient whose differentially diagnose heterophoria It is important to stress that the test
heterophoria is decompensating then it from strabismus, can reveal the type is very different to dissociation tests
is important for the practitioner to and size of the heterophoria (Evans, that measure the magnitude of the
determine why this is happening. If 2005), and the cover test recovery heterophoria whilst the eyes are
there is a non-pathological explanation movement can be used to assess dissociated: in dissociation tests, the
then it is appropriate for the whether the heterophoria is eyes typically view different, non-
optometrist to treat the condition. For compensated (Table 1). In some cases fusible, stimuli (eg, the Maddox rod
example, the optometrist may cure a (eg, young, uncooperative patients or test). In the Mallett fixation disparity
decompensating esophoria by patients who are intellectually test (Figure 3) the eyes are associated:
correcting the underlying impaired) the cover test recovery may they view very similar images which
hypermetropia. As another example, be the only indication as to whether aid sensory fusion. In particular, there
they may help an older patient whose the heterophoria is compensated. is a peripheral fusion lock (the text
long-standing near exophoria is Grade Description around the test) and a central fusion
decompensating due to poor sensory lock (the O X O). The design of the
fusion from untreatable macular fusion lock is probably an important
degeneration by prescribing base in 1 Rapid and smooth feature of the test, and one reason why
prism. If there is a large change in the it is better to use genuine Mallett units
heterophoria for no apparent reason rather than copies.
then this could be a sign of pathology 2 Slightly slow / jerky Whilst in dissociation tests, it is
and the patient requires referral. normal for the eyes to be misaligned,
in the associated Mallett test, the eyes
3 Definitely slow / jerky but not do not usually misalign. Indeed, any
Investigation breaking down misalignment that is reported in this
Symptoms test is potentially abnormal and might
There is no single method which is 4 Slow / jerky and breaks down with be a sign of decompensated
perfect at diagnosing decompensated repeat covering, or only recovers after heterophoria. Recent research shows
a blink
heterophoria, although most cases will that the instructions that are given to
5 Breaks down readily after 1-3 covers
have symptoms. The symptoms can be the patient with this test are important:
classified as visual problems (blur, patients should be asked to say
diplopia, distortion); binocular whether the lines ever move, even by a
problems (difficulty with stereopsis, a < Table 1 very small amount. This is then
tendency to close or cover one eye, A grading system for cover test recovery investigated by adding prism (the
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which says that the two fusional

reserves should not be markedly
different: the divergent fusional reserve
should be more than half the
convergent reserve.

Tests of sensory fusion

A well-compensated heterophoria
requires good sensory as well as motor
40 fusion (Figure 2), and testing of the
sensory aspects of binocular vision can
< Figure 3
be useful in assessing compensation.
9/03/07 CET

The Mallett near fixation disparity test. The left hand picture is for testing horizontal and the right for
vertical heterophoria. The Mallett unit foveal suppression
test is useful for detecting foveal
suppression. This is particularly
aligning prism), starting in ½ prism version of the test is not so good at important in cases where the cover test
dioptre steps, until the lines maintain discriminating patients with and/or fixation disparity test indicate
perfect alignment. A recent study symptoms. This may be because of the that the heterophoria may be
suggests that, when used this way, the different nature of distance decompensated, but the patient does
test is quite good at detecting heterophoric deviations. not report any symptoms. It is possible
symptomatic heterophoria and the Although the Mallett fixation that the patient has foveal suppression
higher the aligning prism the worse the disparity test is very helpful in as a compensatory mechanism to avoid
symptoms are likely to be (Figure 4). diagnosing decompensated symptoms. The use of the foveal
The aligning prism or aligning sphere heterophoria, it is not infallible. In suppression test was described by Tang
is also a useful indication of the some cases, patients will have a and Evans (2005). Stereoacuity tests
prismatic or refractive correction that fixation disparity, yet no symptoms can also be a useful method of
might eliminate symptoms, if it is felt and no need for treatment or assessing sensory fusion.
appropriate to correct the correction. Less commonly, a patient
decompensated heterophoria in this with no fixation disparity may require Other tests
way (see later section on treatment. The other tests in this Dissociation tests such as the Maddox
Management). section can be used to detect these rod and Maddox wing, which measure
Although the Mallett fixation cases. the size of the heterophoria, are not
disparity test is a good indicator of described in detail in this article
decompensated heterophoria at near, Fusional reserves (Figure 5) because the size of the heterophoria is
research suggests that the distance The fusional reserves are a measure of a poor predictor of whether it is
how much vergence the person has ‘in compensated. However, these tests can
reserve’, that can be used to overcome be useful for monitoring the size of the
their heterophoria. The fusional deviation, particularly in cases where
reserves can be measured with rotary the practitioner is concerned that the
prisms, but they are most commonly angle may be changing, which could
measured these days using a prism bar. be a sign of pathology. The cover test is
The fusional reserve that opposes the an essential part of every primary care
heterophoria should be measured first: eye examination and also can be used
base out to force convergence in to monitor the size of deviation (Evans,
exophoria. The patient should fixate a 2005).
detailed target, and the prism is
introduced until the patient reports (i)
blur (if this occurs), (ii) diplopia; and Management
then (iii) the prism reduced until they The first stage in the management of
report single vision. The patient’s eyes decompensated heterophoria is to
should be watched to confirm the remove the cause of the
break point, when the vergence decompensation. For example, if a
< Figure 4 movement should cease. patient has a decompensated
Graph of mean symptom score v. aligning prism at In exophoria, Sheard’s criterion is a heterophoria resulting from poor
near. The error bars represent the standard error useful way of interpreting the fusional sensory fusion owing to unilateral
of the mean (SEM). The number of participants reserves. Sheard’s criterion says that cataract, then cataract surgery may
(shown above scale for horizontal axis) is small for the fusional reserve that opposes the render the heterophoria compensated
higher degrees of aligning prism and this may heterophoria should be at least twice once more. Similarly, a refractive
explain why the SEM increases. Reproduced with the heterophoria. In esophoria, correction for anisometropia may be an
permission from Karania and Evans (2006) Percival’s criterion is more useful, effective treatment. If there is a
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decompensated esophoria owing to deteriorates, especially if the

uncorrected hypermetropia, then the heterophoria angle increases for no
hypermetropia needs to be corrected. If apparent reason, then investigation for
the heterophoria is decompensated incomitancy and referral is required.
because the fusional reserves are low, Indeed, ocular motility testing is an
then eye exercises to increase the important part of the investigation of
fusional reserves are likely to be any binocular vision anomaly,
helpful. although incomitancy is rare in
This simple approach, of finding out heterophoria.
why the heterophoria is 41
decompensating and eliminating or Convergence insufficiency
treating the cause, is often all that is

9/03/07 CET
< Figure 5
required to treat or correct the Overview
condition. This is why much of this Measuring the fusional reserves with a prism bar Convergence insufficiency occurs
article has been devoted to the when the patient has a remote near
investigation of heterophoria: a point of convergence. Confusingly, in
thorough investigation usually reveals goal is to reduce the refractive some literature a convergence
the solution. modification over time, usually weakness exophoria, or
The main approaches to treating checking every 3-4 months. decompensated exophoria at near, is
decompensated heterophoria are Decompensated exophoria at near is often described as a convergence
summarised in Table 2. In any case of easiest to treat with exercises, such as insufficiency. But the two are separate
esophoria, hypermetropia should be the Dinosaur cards or aperture rule conditions which often, but not
suspected and in young patients a trainer, and the IFS exercises always, occur together. For example,
cycloplegic refraction is usually developed at the Institute of Optometry some patients may be orthophoric at
required. When decompensated (IOO) have been found to be successful their reading distance (eg, 40cm), or
esophoria is caused by hypermetropia, as a system of exercises that can be even esophoric, and yet not be able to
then refractive correction is clearly the dispensed by the practitioner for the converge to 10cm. Conversely, many
appropriate management. But even in patient to use at home (Figure 6). patients with a decompensated
emmetropic patients, refractive With any form of treatment, the exophoria at near can converge to a
modification can often be a very useful patient needs to be carefully monitored very close distance, until the target
management strategy. Most to ensure that the treatment plan is reaches their nose. The distinction
practitioners would consider successful. If not, then a new plan is between the two conditions is not just
multifocal spectacles as an option for needed, or referral to a colleague for a academic. From the perspective of
treating decompensated esophoria at second opinion. If the situation treatment, if a patient has a remote
near. Many cases of decompensated
exophoria can also be treated
Intervention Most suitable for Comments
refractively, using a ‘negative add’.
(in descending order)
This is when a patient who may not
have a significant refractive error is Eye exercises Exophoria at near Various methods are available, and a
given negative lenses to induce Exophoria at distance combination of approaches is often helpful
accommodative convergence, hence Esophoria at near
reducing an exophoric deviation. In Esophoria at distance
cases that are managed refractively, the (rarely useful for hyperphoria)
Mallett fixation disparity test is
generally useful for determining the Refractive modification Esophoria at distance & near in In esophoria, latent hypermetropia should
aligning sphere: the minimum latent hypermetropes always be suspected and a cycloplegic
spherical correction that eliminates the Esophoria at near (multifocals) refraction is required for young patients.
Exophoria at distance or near Even in cases without a refractive
fixation disparity. This is usually the
(negative add) aetiology, refractive modification is often
refractive correction that is required,
successful
but this should be checked with a
cover test.
The potential for correction by Prismatic correction Hyperphoria Prismatic correction is occasionally used in
refractive modification is dependent Esophoria exophoria, typically in reading glasses for
on the size of the heterophoria, the Near exophoria older patients
amplitude of accommodation, the
effect of any pre-existing uncorrected Surgery Cyclophoria & hyperphoria Surgery is a last resort for any case of
refractive error, and the amount of Very large esophoria or exophoria heterophoria, and is only rarely required
vergence that is induced by a change
in accommodation (the AC/A ratio). In
any case of refractive management, the < Table 2 Main approaches to treating decompensated heterophoria
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near point of convergence but no more successful (Scheiman et al.,

decompensated exophoria at their 2005). At the very least, push up
reading distance, then eye exercises exercises can be combined with jump
should concentrate on improving the convergence, when a distance target is
near point of convergence. If the patient introduced and the patient alternates
has decompensated exophoria caused fixation between the near and the
by low fusional reserves at the reading distance target. As they do this, the
distance, but can converge to their nose, near target is brought closer in towards
then treatment should concentrate on the eyes. With children, it helps if a
42 increasing the fusional reserves. If the parent can watch the child’s eyes to
patient has both a remote near point of ensure that the appropriate
convergence and low convergent convergence and divergence
9/03/07 CET

fusional reserves then treatment should movements are occurring.

address both deficiencies. A parent watching the eyes will help
< Figure 6 to detect cases in which the patient
Investigation Institute free-space stereogram (IFS)
suppresses at the break point. This is
A measurement of the near point of exercises. Reproduced with permission of important, because these patients may
convergence should be a part of every I.O.O. Sales be unaware of the break point and
routine eye examination. Classically, a need some form of feedback to inform
push-up test is carried out where the them of when their convergence
target is slowly brought towards the heterophoria at an unusually close breaks. Another very useful form of
patient until diplopia occurs. The eyes working distance. feedback can be gained from
should also be watched since often a Rarely, pathology can result in a physiological diplopia. Here, another
break point (when the eyes stop paralysis of convergence. An target is introduced and the patient is
converging) can be observed. This unexpected sudden loss of taught to appreciate this in
should confirm the subjective diplopia convergence would therefore require physiological diplopia. This approach
point, or this may be the only available referral. can be very successful and is described
measure of the end point in patients in more detail in Evans (2002).
who suppress at the break point. There Management Methods based purely on physiological
are various quoted values for the There are only three reasons for diplopia (eg, the three cats card and
normal near point of convergence: treating a binocular vision anomaly: (i) the dinosaur card) are also often
some say a break point of 10cm, others if it is causing symptoms or impaired successful.
8cm. The key thing is the closest performance, (ii) if it is likely to Another approach is to give the
distance at which the patient ever deteriorate if not treated, and (iii) if it patient a self-contained system of
works. Small children might hold a might one day need treatment and exercises, that train convergence in a
book very close, so need better would be more effectively treated now variety of ways. The IFS exercises are
convergence than an adult who works than in the future. So if a patient has a such a system (Figure 6) and can be
on a computer screen at 50cm. slightly remote near point of dispensed to the parent to do at home
Another method of measuring convergence (eg, 12cm) but does not with the child. This system includes
convergence, which is underused, is to work at or near this distance and does self-test questions to ensure that the
assess the jump convergence. The not have symptoms, then they may not exercises are being done properly.
patient is asked to alternate their require treatment unless the situation
fixation between a distant target and deteriorates. An exception may be Accommodative anomalies
one at 15cm. A prompt and smooth patients, often children, who do not
convergence movement should be seen appreciate symptoms until these have Overview
between distance and near and a been corrected. This article will not cover
failure of this can indicate abnormal Convergence insufficiency can nearly accommodative anomalies in great
convergence (Pickwell and Stephens, always be treated successfully with eye detail, since the emphasis of the article
1975). exercises. The simplest are push-up is on heterophoria. However, no
The symptoms of convergence exercises, where the target is slowly assessment of near heterophoria in a
insufficiency are similar to those of brought towards the patient’s nose pre-presbyopic patient is complete
decompensated heterophoria. Of whilst the patient tries to keep it without an investigation of
course, the condition will only cause single. If the accommodation is accommodation. This is particularly
symptoms if the patient carries out adequate, or needs training as well (see true for convergence weakness
tasks at a distance at which the next section) then the target should exophoria and convergence
convergence insufficiency will cause have fine detail and the patient should insufficiency. Indeed, it has been
problems, such as threading a needle. try to keep the target clear as well argued that accommodative
The diagnosis of convergence as single. insufficiency is the primary cause of
insufficiency is often helped by There is some evidence that more symptoms in patients with
carrying out tests for decompensated sophisticated exercise regimens are convergence insufficiency (Marran et
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al., 2006). Recent GOC disciplinary

Symptoms/test Accommodative Accommodative Accommodative Accommodative
cases concerning children reveal that
results insufficiency infacility fatigue spasm (excess)
assessments of accommodative
function are often missing from Symptoms Near blur Difficulty changing Near blur towards Transient blur of
practitioners’ record cards, which is a focus (e.g. copying end of day distance or near
cause for concern. Accommodation can from board) vision
be measured in several different ways, Accommodative Low Normal Declines with repeat Normal
but at least an assessment of amplitude testing
accommodative amplitude should be
included in any child’s eye Accommodative May be slow with Poor Declines with May be slow with
facility minus lenses repeat testing plus lenses 43
examination.

9/03/07 CET
Accommodative Need high plus Normal Initially OK, Need negative
Investigation lag (>+0.75) increasing plus after lenses
The four main types of accommodative much near vision
anomalies are summarised in Table 3.
Rarely, pathology can result in a < Table 3 Clinical characteristics of the four main types of accommodative anomalies
paralysis of accommodation. An
unexpected sudden loss of
accommodation would therefore cpm (Zellers et al., 1984). If there is an is of course only carried out on one
require referral. abnormal test result binocularly, the eye at a time, usually only in the
It is essential in any child with test can be repeated monocularly. horizontal meridian.
presumed accommodative dysfunction These norms for the accommodative Typically a “with” movement is seen
to know the full refractive error. An facility test show that the normal range indicating that the accommodation is
apparent accommodative problem of responses is very wide, no doubt lagging behind the target (plus lenses
could result from latent reflecting the highly subjective nature need to be added). An “against”
hypermetropia, so a cycloplegic of the test. An extremely useful movement suggests accommodative
refraction is usually required. objective test of accommodative spasm (see Table 3). Spherical lenses
The simplest measurement of function is to measure accommodative are introduced of a power that it is
accommodative function is the push- lag. This is a form of dynamic thought will neutralise the reflex. For a
up test: typically, the child is asked to retinoscopy which is carried out at the typical “with” movement, the first lens
read detailed text as it is slowly patient’s usual reading distance, whilst might be +0.50. The lens is introduced
brought towards the eye. The text the patient wears any refractive monocularly and is rapidly interposed:
should be random words or letters, so correction that they usually use for it should be present for no more than
that words cannot be guessed from reading. The patient fixates a target on ½ a second. This should be just long
context e.g. the I.O.O. fixation stick. the retinoscope. Because the target is enough for a “sweep” of the
Norms for accommodative amplitude in the plane of the retinoscope, no retinoscope to see if the reflex is now
are given in Table 4. correction needs to be made for neutralised, and the procedure is
The rate of change of working distance. The target is viewed repeated using different lenses until
accommodation, or accommodative binocularly, although the retinoscopy the reflex is neutralised. The process is
facility, can be tested with flippers. then repeated for the other eye.
These are two pairs of lenses mounted The normal range of response (mean
on a stick so as to form a binocular Age (yrs) Minimum (D) Minimum (cm) ± 1.00D) is plano to +0.75D. This test
twirl. Typically, +2.00DS and –2.00DS is particularly useful for cases who
lenses are used. The patient views a 4 14.00 7.00 report blur during accommodative
detailed target, ideally with 6 13.50 7.50 testing, or indeed at any time during
suppression checks, at their usual the eye examination which suggests
8 13.00 7.75
reading distance. The practitioner accommodative dysfunction, but
holds up the pair of +2.00D lenses and 10 12.50 8.00 where the practitioner is suspicious
the patient reports when the target 12 12.00 8.25 that there may be a visual conversion
becomes clear. The lenses are then (hysterical) reaction.
‘flipped’ to the pair of –2.00D lenses. 14 11.50 8.75
When the text is clear, the practitioner 20 10.00 10.00 Management
‘flips’ again, and so on. The number of There are two options for the
flips that can be completed in a minute 30 7.50 13.25 management of accommodative
is counted and halved to give the 40 5.00 20.00 anomalies: eye exercises or spectacles.
number of cycles per minute (cpm). The main types of eye exercises are
The binocular test norms are that about 50 2.50 40.00 push up (like push up convergence
90% of the population perform better exercises but with the emphasis on
than 2.7 cpm and about 50% of the < Table 4 Norms for accommodative keeping the target clear) and flippers.
population perform better than 7.7 amplitude measured by the push-up test With flipper exercises, the patient is
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given flip lenses of a power that they comfort. This does not replace the described above.
can cope with (e.g., ±1.00) and they try need for specialist teaching, but Other visual anomalies (eg,
to improve their speed with these, and means that the person will be more significant refractive error, strabismus)
then build up the power. likely to benefit from this extra are not specifically correlated with
If accommodative insufficiency or teaching. dyslexia, but can, of course, occur in a
fatigue (Table 3) does not respond to dyslexic child just as they can in any
eye exercises, or if the patient is not Investigation other child. Although not causes of
willing to do eye exercises, then the The main visual problems that are dyslexia, these problems would
condition can be corrected with correlated with dyslexia are Meares- represent an added burden for a
44 spectacles. These might take the form Irlen syndrome/visual stress (MISVIS), dyslexic child and should therefore be
of reading spectacles, but more often binocular instability, and detected and treated.
bifocal or progressive addition lenses accommodative insufficiency. It is
9/03/07 CET

will be required. helpful if a person with dyslexia can Management

see an optometrist who has specialised When people with dyslexia consult an
in this subject and can carry out a eyecare practitioner they need a
Specific learning detailed special investigation to look detailed visual assessment to
difficulties (dyslexia) for the symptoms and signs of these determine whether any of the above
problems. Typically, this requires an factors are present. It is not uncommon
Overview additional appointment for tests that for the practitioner to find signs of
Dyslexia affects 5% of the population would not normally be included in a MISVIS and also subtle signs of
and can have many causes. We are not normal eye examination. This subject binocular instability, and this leads to
all equally good at everything that we can only be summarised in the present a dilemma: which should be treated
do. When children have specific article (for more information, see first? If there is a clear motor problem
difficulties with some academic skills Evans, 2004a-c). (eg, a marked deficit of convergence or
then they are sometimes described as The most common visual correlate of very low fusional reserves) then the
having specific learning difficulties. dyslexia seems to be MISVIS. This treatment of this condition is a priority.
Usually, this term will only be used condition is characterised by This is particularly important if the
for people with a marked problem; for symptoms, on viewing text, of visual heterophoria is at risk of breaking
example, people of average perceptual distortions (text moves, down into a strabismus.
intelligence whose performance in the blurs, doubles, and shapes and It is more common to find that,
specific subject falls in the bottom 5% patterns are seen on the page) and when binocular instability coexists
of the population. The most ‘1eyestrain’ and headaches. There is with MISVIS and dyslexia, the
commonly diagnosed form of specific accumulating evidence suggesting that binocular instability is very subtle.
learning difficulty is specific reading the cause of the condition is Typically, the reported benefit from
difficulty. This is almost always hyperexcitability of the visual cortex: a coloured filters is very marked
associated with specific spelling sort of ‘overload’ occurs from viewing compared with, for example, the effect
difficulty and is often called dyslexia. high contrast striped patterns such as of a prismatic correction or occlusion
Dyslexia attracts more attention than text. The intervention that seems to be on the binocular anomaly. MISVIS is
other specific learning difficulties most helpful is individually prescribed an anomaly of sensory processing and
because reading is a skill that is coloured filters (see below). The this condition will impair the clarity of
central to so many academic investigation of the condition includes the monocular percepts, which will
activities. a detailed analysis of symptoms, make sensory fusion more difficult
Dyslexia describes a problem that testing with coloured overlays, the (Figure 2). In cases where any
can have many causes. There is very Wilkins rate of reading test, the pattern binocular vision anomaly is subtle
good scientific evidence indicating glare test, and the MRC intuitive (borderline), then it is often best to
that most people with dyslexia have a colorimeter and precision start by correcting the MISVIS. The
difficulty with phonological decoding: tinted lenses. patient can be seen again a few months
they have trouble translating text into Binocular instability is sometimes after collection of their precision tinted
the sound units that are needed to found in dyslexia. The condition is lenses to investigate whether the
pronounce and understand what they related to decompensated heterophoria binocular vision anomaly is still
are reading. In some cases of dyslexia, and is characterised by symptoms of present once their sensory perception
there is also a visual component to blur, diplopia, and eyestrain and has been improved.
the problem. In these cases, the headaches. Clinically, there will be low If binocular instability does require
optometrist can help. The optometrist fusional reserves and an unstable treatment then fusional reserve
should not expect to cure the heterophoria (eg, unstable green exercises usually are the most
dyslexia, but if they treat a visual strip(s) on the Mallett fixation appropriate treatment.
problem that is contributing to the disparity test). MISVIS is usually diagnosed on the
person’s difficulties then they are Accommodative insufficiency is basis of symptoms and an
likely to help that person to read for infrequently found in dyslexia. The improvement with coloured overlays,
longer with greater clarity and investigation of this condition is either over time or via an immediate
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increase in speed of reading. References

Randomised controlled trials show Bulk subscriptions
that the optimum treatment for Evans, B. J. W. (2001). 'Dyslexia and
MISVIS is individually prescribed Vision.' (Whurr: London.)
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coloured lenses: different people need Evans, B. J. W. (2002). Optometry Today is the highest
different colours and the colour needs 'Pickwell's Binocular Vision circulated journal within the
to be prescribed with some precision. Anomalies.' 4th edition optometry market
It is a cause of concern that some (Elsevier: Oxford.) Receive 24 copies for as little as
approaches prescribe colours without Evans, B. (2004a). £110 UK and £150 Overseas
precision (eg, using a range of only a The role of the optometrist in for a single copy subscription 45
few colours) since most research dyslexia. Part 1, Specific learning
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9/03/07 CET
appropriate way of correcting January 30th, 29-34 OT tells you all you need to know in
MISVIS. In the UK, the MRC Intuitive (www.optometry.co.uk/pages/articles) practice – the latest on important
Colorimeter system seems to be most Evans, B. (2004b). The role of the issues and new thinking within the
widely used and the research support optometrist in dyslexia. Part 2: optometry and dispensing optics
for this system is now considerable. Optometric correlates of dyslexia. industry within the UK and beyond.
When people are prescribed Optometry Today February 27, 35-39 The programme for 2007 includes
coloured filters, the required colour (www.optometry.co.uk/pages/articles) all the features you want to read:
should be monitored, usually yearly. Evans, B. (2004c).
• News about the profession in
The optimum colour sometimes The role of the optometrist in
changes over time. The NHS optical dyslexia. Part 3: Coloured filters.
the UK and overseas
voucher can be used to make a Optometry Today 26 March, 29-35
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contribution towards the cost of these (www.optometry.co.uk/pages/articles) • In store display systems
tinted lenses if the patient requires Evans, B. J. W. (2005). • Eye Fashion today supplement
correction of a refractive error, but 'Eye Essentials: Binocular Vision.' • Conference previews and reviews
cannot be used if there is no (Elsevier: Oxford.) • Children’s frames
refractive error. The Department of Marran, L. F., De Land, P. N., and • Sunglasses
Health is aware of the inconsistencies Nguyen, A. L. (2006). • Developments in Glaucoma
inherent in this provision, and it is Accommodative insufficiency is the diagnostic testing technology
hoped that proper NHS funding of the primary source of symptoms in • Development in low vision
testing and prescribing of these children diagnosed with convergence • Development in safety eyewear
interventions will one day be insufficiency. Optom Vis.Sci 83, • Practice interiors and displays
available. 281-289. • Eye fees – monthly payment
It is important to emphasise Pickwell, L. D. and Stephens, eye care schemes
that any optometric intervention for L. C. (1975). Inadequate convergence. • Financial services
people with specific learning British Journal of Physiological
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difficulties will only address the Optics 30, 34-37.
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visual component of the person’s Scheiman, M., Mitchell, G. L.,
subscription now!
difficulties, and will not take Cotter, S., Cooper, J., Kulp, M.,
away the need for specialist teaching. Rouse, M., Borsting, E., London, • 10 copies £780
But there is some evidence that R., and Wensveen, J. (2005). • 25 copies £1,800
MISVIS, which can also occur in A randomized clinical trial of • 50 copies £2,400
good readers, is not only more treatments for convergence • 100 copies £4,200
prevalent in people with dyslexia insufficiency in children. • Further single copies will be
but is also more of a problem for Arch Ophthalmol 123, 14-24. charged at £36
people with dyslexia than for people Tang, S. T. W. and Evans, • 100 extra copies charged
who are good readers. B. J. W. (2005). The Near Mallett at £3,600
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Optometry Today 45, 36-39
contact our subscriptions
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Module questions Course code: c-5196

Please note, there is only one correct answer. Enter online or by form provided
An answer return form is included in this issue. It should be completed and returned to CET initiatives (c-5196) OT,
Ten Alps plc, 9 Savoy Street, London WC2E 7HR by April 4 2007.
1. Which one of the following is the strongest indication of a need for a 7. The following statements refer to fusional reserves. Which one is incorrect?
cycloplegic refraction in a young patient? a. During the test, children should fixate an accommodative (detailed) target
a. A decompensated hyperphoria b. The fusional reserve that opposes the heterophoria should be measured first
b. A decompensated exophoria c. In exophoria, the fusional reserve that opposes the heterophoria is
c. A decompensated esophoria measured with base in prisms
d. Accommodative lag on MEM retinoscopy of +0.50 d. The prism should be reduced until the patient reports single vision after diplopia
46
2. Which one of the following is least likely to be a symptom of 8. In determining whether to treat a case of decompensated exophoria by
decompensated heterophoria? refractive modification, which of the following is the least important factor
9/03/07 CET

a. Metamorphopsia to consider?
b. Blurred vision a. The amplitude of accommodation
c. Sore and tired eyes b. Whether the patient prefers spectacles or contact lenses
d. Headaches c. The effect of any pre-existing uncorrected refractive error
d. The AC/A ratio
3. Which one of the following is least likely to contribute to a heterophoria
becoming decompensated? 9. Which one of the following statements about accommodative
a. Low fusional reserves anomalies is incorrect?
b. An impairment to sensory fusion a. Patients with accommodative insufficiency will, on testing with flippers, be
c. Dyslexia slower to clear plus lenses than they are to clear minus lenses
d. An increase in the size of the heterophoria b. Patients with accommodative fatigue are likely to report near blur towards
the end of the day
4. The following statements refer to the Mallett fixation disparity test. c. Patients with accommodative infacility are likely to have problems copying
Which one is correct? from the board
a. It detects the presence of an aligning prism and measures fixation disparity d. Patients with accommodative spasm are likely to need negative lenses
b. It detects the presence of an aligning sphere and measures fixation disparity when their accommodative lag is tested
c. It detects the presence of fixation disparity and measures the size of
the heterophoria 10. Which of the following would be easiest to treat with fusional
d. It detects the presence of fixation disparity and measures aligning reserve exercises?
prism or sphere a. Hypermetropia
b. Accommodative insufficiency
5. Which of the following is correct? The cover test can provide the c. Decompensated esophoria at near
following information: d. Decompensated exophoria at near
a. Differentially diagnose strabismus from heterophoria
b. Indicate whether a heterophoria is compensated 11. Dyslexia affects what proportion of the population?
c. Estimate the size of the deviation a. 5%
d. All of the above b. 10%
c. 15%
6. Which of the following is the correct description of Sheard’s criterion? d. 20%
a. The fusional reserve that opposes the heterophoria should be at least twice
the heterophoria 12. Which one of the following is incorrect?
b. The fusional reserve that opposes the heterophoria should be at least half a. The main visual correlates of dyslexia are Mearles-Irlen syndrome / visual
the heterophoria stress (MISVIS), binocular instability, and accommodative insufficiency
c. The fusional reserve that opposes the heterophoria should be at least one b. Meares-Irlen syndrome causes unstable visual perception which may
third of the heterophoria contribute to binocular instability
d. The fusional reserve that opposes the heterophoria should be at least twice c. Meares-Irlen syndrome is easily corrected with blue lenses
the size of the other fusional reserve d. Binocular instability may be corrected with eye exercises

Please complete on-line by midnight on April 4 2007 - You will be unable to submit exams after this date – answers to the module will be published in our April 6 issue
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CET answers Course code: c-5193

These are the correct answers to Module 10 Part 2, which appeared in our February 9th, 2007 issue
1. Correct answer is B 7. Correct answer is A
The Hall Report (2003) recommended that in the UK, orthoptists should undertake Woodhouse (1998) found that accommodation is reduced in children with Down’s
vision screening once the child is in education. This should be carried out at syndrome and Stewart et al (2005) found that because of their reduced
between 4-5 years of age. accommodation, these children benefit from wearing bifocal spectacles. They advised
giving a +2.50D addition with the segment top in line with the pupil.
2. Correct answer is C
A child of 18 months is not usually interested in Keeler cards and is too young to 8. Correct answer is B 47
reliably name picture cards. The Cardiff cards are ideal to use between the two According to the work by Mutti et al (2000) myopes have the highest AC/A ratio, while
stages as those children who can name the pictures, will do so, and otherwise they emmetropes have a lower AC/A ratio with hypermetropes having the lowest AC/A

9/03/07 CET
can act as preferential looking cards. ratio.

3. Correct answer is D 9. Correct answer is D

Print should be made available that is 3 times the size of the smallest print that a Whilst adequate cycloplegia is achieved 20 minutes after instillation, more complete
child can just manage in order to make it easy for the child to be able to see the cycloplegia is found after 30 – 40 minutes.
print clearly.
10. Correct answer is D
The Mohindra technique does not relax the accommodation and as a result, dilation
4. Correct answer is A will elicit more plus prescription than Mohindra. Borghi and Rouse (1985) found that
By the age of 5 years, child with normal vision should be able to see N5 print but dilated retinoscopy produced 0.50 – 0.75 more plus than the Mohindra technique.
should not be given this size to work with.
11. Correct answer is C
5. Correct answer is B Ciner et al (1991) found the near stereo acuity should be 60 seconds of arc by age 5
Young infants are likely to exhibit abnormal ocular alignment but years and Kulp & Mitchell (2005) suggested that most 4-year-olds should have a
Sondhi et al (1988) suggested that intermittent exotropia should stop by the age of stereoacuity of at least 70 seconds of arc while most young school-aged children
6 months. should have at least 50 seconds of stereoacuity. Adult levels of contrast sensitivity
are reached by the age of 10 years.
6. Correct answer is D
Base out prism stimulates motor fusion. When a base out prism lens is placed in 12. Correct answer is B
front of one eye, both eyes should move in the direction of the prism apex. If there is Children with learning difficulties may not be able to concentrate for long and the
binocular fusion, the eye not being covered by the prism should be seen to refixate to most important tests should therefore be carried out first. Parts of the routine eye
the centre in order to overcome diplopia. examination will not be possible to carry out at all.