Orthoptics for the busy The College of optometrist Optometrists - PDF document

Orthoptics for the busy The College of optometrist Optometrists Welcome to our webinar Interactive CET point 1 Professor Bruce Evans BSc (Hons) PhD FCOptom FAAO FEAOO FBCLA DipCLP DipOrth Director of Research, Institute of Optometry 22 January 2020 1 2 Interactive CET point How to ask questions iPhone Android Desktop • Answer min four Submit poll poll questions • Remain in webinar for at least 50 mins • Complete feedback form 3 4 For regular tweets on optometric research: DISCLOSURE PLAN Paid lectures & KOL/product feedback programmes: Alcon, American Academy of Optometry (UK), Association of INTRODUCTION Optometrists, Birmingham Focus on Blindness, Black & Lizars, Central (LOC) Fund, Cerium Visual Technologies, College of Optometrists, Coopervision, ESRC, General Optical Council, Hoya, Institute of Optometry, International Institute for Colorimetry, Iris Fund for Prevention INVESTIGATION OF INCOMITANCY of Blindness, Johnson & Johnson, Leightons, London Vision Clinic, MRC, Norville, Optos, Paul Hamlyn Trust, Perceptive, Scrivens, Specsavers, Thomas Pocklington Trust. INVESTIGATION OF HETEROPHORIA Lecture content always my own Author of Pickwell’s Binocular Vision Anomalies, INVESTIGATION OF HETEROTROPIA editions 3-5 i.O.O. Sales Ltd markets IFS orthoptic exercises, which TREATMENT the speaker designed, and for which he receives a small royalty CONCLUSIONS Director of a community optometric practice in Brentwood, Essex Full handout of slides from www.bruce-evans.co.uk 5 6 1

OVERVIEW: CAVEAT >5% of patients seeing community Poll question 1 optometrists have BV problems Always look for pathology: Neuro-optometric checks Pupils, discs, fields, strabismus, incomitancy, accommodation Check these things regularly Don’t forget refraction Change management if not improving significantly Refer if still not improving Appropriate re-exam intervals (frequent) 7 8 For regular tweets on optometric research: PLAN CAUSES OF INCOMITANCIES VASCULAR NEUROLOGICAL OTHER INTRODUCTION Tumours Trauma Diabetes INVESTIGATION OF INCOMITANCY Hypertension Multiple sclerosis Thyrotoxicosis INVESTIGATION OF HETEROPHORIA Myasthenia gravis Toxic Stroke Aneurysms Migraine Iatrogenic INVESTIGATION OF HETEROTROPIA Idiopathic Temporal arteritis TREATMENT CONCLUSIONS Full handout of slides from Underlined = more likely in elderly www.bruce-evans.co.uk 9 10 Motility test Poll question 2 Use reliable pen torch Check nose not occluding Really, three tests, so do three times: Observe corneal reflexes 1) Cover test in peripheral gaze 2) Ask about diplopia 3) Beware of reports of diplopia May break down (in view of target, distance, fus. res.) May be variable May be confused Know the muscle actions (RADSIN) 11 12 2

MOTILITY DIAGRAM ACTIONS OF SUPERIOR MUSCLES SR IO IO SR LR MR MR LR IR SO SO IR 13 14 PLAN Incomitancies: the bottom line INTRODUCTION Some incomitancies are difficult to detect INVESTIGATION OF INCOMITANCY If symptoms are suspicious, do cover testing in INVESTIGATION OF HETEROPHORIA peripheral gaze Testing for cyclo-deviations detects SO palsies INVESTIGATION OF HETEROTROPIA Refer new or changing incomitancies TREATMENT In some long-standing cases, prescribing the prism required in the primary position may help CONCLUSIONS Full handout of slides from www.bruce-evans.co.uk 15 16 Signs of decompensated phoria Grade Description � Symptoms 1 rapid and smooth 2 slightly slow/jerky 3 definitely slow/jerky but not breaking down DISSOCIATED HETEROPHORIA 4 slow/jerky and breaks down with repeat � Poor cover test recovery covering, or only recovers after a blink 5 breaks down readily after 1-3 covers � Some information can be Scale obtained from recovery 3.00 motor sensory 2.0 1.8 fusional reserves fusion lock movement, but 1.6 fusion fusion 1.4 2.00 1.2 orthophoria hyperphoria 1.0 � No data on sensitivity & 1st appt. difference (TP-BE) specificity of this 1.00 COMPENSATED or NOT esophoria exophoria Cover test dynamics are 0.00 � complex (Barnard & Thomson, 1995 -1.00 -2.00 Evans (2007) Pickwell’s Binocular -3.00 Vision Anomalies 0.00 1.00 2.00 3.00 4.00 5.00 Panesar & Evans, in preparation 1st appt. mean (TP & BE) 17 18 3

KEY SIGNS OF DECOMP. PHORIA ALIGNING PRISM : Mallett Unit � Symptoms • aligning prisms/spheres to eliminate FD � Poor cover test recovery • good foveal and peripheral fusion lock • question set is important � Aligning prism (FD test) • ask if a line ever moves � Low fusional reserve opposing phoria • Karania & Evans (2006) 1.0 � Sheard’s criterion 1  + • for symptomatic phoria: 1  + � Particularly useful for exophorias .8 • sensitivity 75% 2  + .6 � For esophorias, size and imbalanced fusional • specificity 78% .4 reserves are relevant 2  + 3  + aged 40 years .2 • Jenkins, Pickwell, and over & Yekta (1989) 3  + under the age � For hyperphorias, size matters 0.0 of 40 years 0.0 .2 .4 .6 .8 1.0 1-SPECIFICITY 19 20 ALIGNING PRISM : Mallett Unit • Maintain normal binocular vision Poll question 3 • Increase lighting, full field of view • Use hand held loose prisms • Minimum prism for alignment • Re-normalise BV between prisms • Prism dioptre steps: 0.5, 1.0, 2.0, 4.0 1.0 1  + 1  + .8 2  + .6 .4 2  + 3  + aged 40 years .2 and over 3  + under the age 0.0 of 40 years 0.0 .2 .4 .6 .8 1.0 1-SPECIFICITY 21 22 STEREOTESTS KEY SIGNS OF DECOMP. PHORIA www.bernell.com � Poor cover test recovery � Aligning prism � Low fusional reserve opposing phoria � Sheard’s criterion � Particularly useful for exophorias � For esophorias, size and imbalanced fusional reserves are relevant, consider cycloplegia � For hyperphorias, check comitancy carefully 23 24 4

For regular tweets on optometric research: PLAN INTRODUCTION DISSOCIATED HETEROPHORIA INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA motor sensory fusional reserves fusion lock fusion fusion INVESTIGATION OF HETEROTROPIA NOT COMPENSATED TREATMENT CONCLUSIONS STRABISMUS Full handout of slides from www.bruce-evans.co.uk 25 26 Strabismus: the bottom line for the busy optometrist Strabismus: the bottom line for the busy optometrist is it new or changing? is it new or changing? yes no yes no A A M M do I know the cause? any treatment needed? do I know the cause? any treatment needed? (probably not) (probably not) B B L L yes no yes no Y Y e.g., hypermetropia REFER e.g., hypermetropia REFER O O P P can I correct it? can I correct it? I I A A yes no yes no e.g., Rx REFER e.g., Rx REFER sorted! sorted! 27 28 For regular tweets on optometric research: PLAN INTRODUCTION Poll question 4 INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS Full handout of slides from www.bruce-evans.co.uk 29 30 5

TREATMENT OF AMBLYOPIA (a) Flow chart based on review of recent RCTs in Evans et al. (2011; OPO) Many cases of amblyopia can be cured by refractive correction alone; Poll question 5 20% don’t need occlusion (Gibson, 1955; Pickwell, 1984; Stewart et al., 2004; West & Williams, 2011) Contact lenses are likely to be best in anisometropia (Evans, 2006) Many cases never require full-time occlusion If 6/9 to 6/25, 2h occ. ≡ 6h If ≤ 6/30, 6h > 2h Avoid full time occlusion for orthotropic anisometropia Timings approximate See patients frequently during the treatment of amblyopia, to begin with every 4-6 weeks 31 32 MOTOR DEVIATION: MOTOR DEVIATION: REFRACTIVE CORRECTION : OVERVIEW REFRACTIVE CORRECTION : SPECIFICS • Mandatory in accommodative esotropia • determine sphere that • Also possible to treat convergence – eliminates strabismus (no diplopia) excess with multifocals & exo- – eliminates FD on Mallett Unit deviations with negative lenses • prescribe, try to reduce approx. every 3-6/12 • limited by 4 factors • negative adds (Chen et al., 2016) and – angle of deviation bifocals/varifocals can work well – refractive error – accommodation – AC/A ratio 33 34 MOTOR DEVIATION: MOTOR DEVIATION: REFRACTIVE CORRECTION : CASE STUDY: D1542 PRISMATIC CORRECTION : OVERVIEW • preferred treatment in • 11/5/96, female, age 8y, 1 headache a fortnight small/moderate vertical deviations – wearing full cyclo plus (c. +2.00, R=L) – cover test: D: 8  SOP N: 10  RSOT • may also help in small/moderate – with +2.00 add: N 4  RSOT with +2.50 add: N ortho horizontal deviations if not amenable to refractive modification or exercises Date May 96 July 96 Mar 97 Jun 97 Sep 97 Jan 98 Apr 98 Jun 98 Sep 98 Add +2.50 +3.00 +2.50 +2.00 +1.75 +1.50 +1.00 +0.50 None • limited by angle of deviation / cosmesis of prism 35 36 6