Guide Binocular Vision & Orthoptics. Investigation and Management

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Eye should be clean and clear during orthoptic examination. Normal time required is 5 to 10 minutes for normal eye. Time taken is between 15 to 20 minutes in abnormal eye eye with some kind of deviation. It is a part of routine eye examination so it is included in consultation charges, but after examination if some eye exercizes are required ,they are chargeable and the cost may vary from one hospital to the other.

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Store Description Thank you for taking an interest in one of our books. We are a mail-order only bookstore located in Bellingham, WA specializing in modern out-of-print books of all genres. Large vertical deviations may cause loss of binocular vision, a cosmetically objectionable hypertropia, and frank diplopia.


In vertical deviations due to superior oblique muscle palsy, compensatory torticollis is common, with the face turn or the head tilt toward the opposite shoulder. These values are clinically significant and require treatment, however, only if they produce symptoms.

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Von Noorden noted, however, that the clinical significance of vertical deviations and other heterotropias depends not so much on their absolute values as on correlated findings, for example, the fusional amplitudes. The evidence on the effectiveness of orthoptic treatment for vertical deviations is sparse and contradictory. Based on his clinical experience, Layland stated that hypertropias are unlikely to respond to orthoptic treatment. Mann , commenting on her experience, concluded that paralytic forms of vertical deviations never respond to orthoptic treatment, but orthoptic treatment can help some patients with non-paralytic vertical deviations.

The AOA position statement on vision therapy for strabismus only mentions its use in esotropia and exotropia American Optometric Association, undated. There is no statement about its effectiveness in vertical deviations. S ix studies were identified; all of these studies combined reported on the results of orthoptics in fewer than 70 patients. All of these studies involved retrospective review of optometric records. None of these studies employed control or comparison groups.

And none of these studies provided statistical analysis of the results.

The 2 largest studies Ettinger, ; Ludlam, excluded drop-outs from the analysis, and Ludlam also excluded from analysis patients who were still completing treatment. Zaki and Etting found lower functional cure rates in strabismus patients with than in strabismus patients without vertical deviations. Ludlam found, however, that cure rates for horizontal strabismus were the same regardless of whether there is an associated vertical deviation. Only a few small studies have reported on the effectiveness of orthoptic treatment of vertical deviations.

Cooper described 4 patients with large vertical deviations -- 3 patients with intermittent hypertropias and 1 patient with an alternating hyperesotropia range of deviation 6 to 12 diopters of vertical tropias -- that were treated with a combination of prismatic glasses and orthoptics.

Finally, no conclusions about the effectiveness of orthoptic treatment of patients with vertical deviations can be drawn from these selected case reports. Zaki reported on the results of orthoptic treatment of children ages 5 to 7 years with less than 12 degrees of strabismus, including 10 children with hypertropia, 6 with accompanying exotropia and 4 with accompanying esotropia. The children received a total of 12 weeks of twice-weekly orthoptics 24 visits. The rest of the patients needed surgery. Only 3 of the cases exhibited any vertical deviation in all 3 cases, the vertical deviation was associated with esotropia , and their results with orthoptic treatment were not reported separately.

One of the largest study of the effectiveness of orthoptics for patients with vertical deviations was by Etting , who reviewed the optometric records of 86 patients ages 6 to 40 years with strabismus who had orthoptics, including 13 patients with vertical deviation, all of whom had an associated exotropia.

Vision Therapy

Subjects were excluded if the onset of strabismus occurred before age 6, or if they dropped out before completing 24 office visits were also excluded from the study. The investigators measured both functional cure rates and cosmetic cure rates. A functional cure included clear, comfortable vision, normal near point of convergence, stereopsis, and normal fusion ranges. Cosmetic cure was defined as a final angle of deviation of 15 prism diopters or less, or if less deviation was present at study entry, improved anomalous fusion.

Of 13 subjects with vertical deviations and exotropia, 6 In addition, up to one-half hour of home therapy was assigned. An average of 48 sessions of office therapy were used to treat patients with vertical deviations.

What does an orthoptist do?

Ludlam reviewed the medical records of patients seen at an orthoptic clinic over a 4-year period, of whom had strabismus. The results of the remaining cases were reported. Patients received office orthoptic training either once or twice-weekly, supplemented in almost all cases with home exercises. Functional cures were those who had clear comfortable binocular vision, normal near point of convergence, stereopsis, and normal ranges of motor fusion. Of the 17 patients with hyper-esotropia, 4 This compares to a functional cure rate of Thus, the presence of a vertical component did not appear to affect the cure rates for esotropia and exotropia.

Ludlam noted that this finding contradicts previous reports that vertical deviation was an important impediment to functional cure by orthoptics. For patients achieving a functional cure, the average number of office sessions was 23 for exotropia and 32 for esotropia. In a subsequent study, Ludlam reported on the long-term outcomes or orthoptic treatment of strabismus. In , the investigator re-examined 82 patients from the earlier study who were judged to be at least moderately cured at the time of their dismissal from vision training between and Of 12 patients with hyperesotropia that returned in for re-examination, 5 had improved since dismissal from training, 5 remained unchanged, and 2 deteriorated.

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  • Of 14 patients with hyper-exotropia that returned, 6 improved since dismissal from training, 9 were unchanged, and 2 deteriorated. There was wide variation in the number of office visits necessary for treating vertical deviations. Zaki and Ludlam reported average treatment durations of 32 visits or less, whereas Etting reported an average treatment duration of 48 visits.

    In contrast to the scattered reports on the effectiveness of orthoptics for vertical deviations, there have been published the results of larger prospective case series of surgery for vertical deviations. Saunders reports that surgical oblique muscle strengthening, often performed in combination with surgery of other extraocular muscles, is effective in incomitant hypertropia due to superior oblique muscle palsy.


    However, it is not known whether early strabismus surgery will prevent or reverse the postural plagiocephaly due to chronic torticollis. The majority of patients undergoing superior oblique tendon tuck for appropriate indications will not require a second surgery Saunders, Davis and Biglan state that re-operation for vertical deviations is required in patients with diplopia and vertical deviation is greater than 5 prism diopters.

    Other indications for re-operation include residual head postures or tilts. If the amount of residual or new torticollis exceeds 10 or 15 prism diopters, it is sufficient to warrant consideration of additional surgery. Vertical deviations may occur as a new finding after horizontal strabismus surgery, or they may occur as a result of under-correction or over-correction of a previous hypertropia Davis, Vertical deviations may also occur de novo as part of the natural history of a strabismus condition, such as dissociated vertical deviation following horizontal correction of infantile esotropia.

    Sprague reported that the Fadenoperation may be an alternative in the treatment of patients with dissociated vertical deviations spontaneous supraduction of either eye when the patient is fatigued or day-dreaming. But Esswein et al retrospectively compared the superior rectus Fadenoperation to large superior rectus recessions for dissociated vertical deviation and found better results with recession alone.

    Buckley noted that there was little information about the effectiveness of botulinum toxin injections in the treatment of vertical strabismus, and in some instances, botulinum toxin would be contraindicated. Although a comprehensive review of studies of the effectiveness of surgery for vertical deviations is beyond the scope of this assessment, one of the early studies of the effectiveness of surgery in vertical deviations is described below.

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    • Lyle and Foley reported on the results of surgery, with and without orthoptics, in patients with congenital paralytic strabismus; of the patients, 92 had binocular vision preoperatively and 15 did not. The outcome of the study included absence of symptoms, and restoration of single binocular vision, including equal visual acuity, normal retinal correspondence, fusion, and stereopsis.

      Of the 15 patients with no binocular vision, 3 had palsy of the horizontally acting extraocular muscles, 7 had a palsy of vertically acting muscles with secondary esotropia, and 5 had a palsy of vertically acting muscles with secondary exotropia. Orthoptic treatment was not given in any case; treatment consisted only of an operation to improve cosmetic appearance. Of the 92 congenital paralytic strabismus patients with binocular vision, 76 had a vertical deviation Lyle and Foley, Of the 76 with a vertical deviation, 13 had an associated horizontal deviation and 63 did not.

      Of the 63 patients with an isolated vertical deviation, 55 complained of symptoms preoperatively. Fifty-one of the 55 symptomatic patients had complete relief and the other 4 had partial relief of symptoms following surgery. Of the 8 patients with isolated vertical deviations who did not have symptoms, 7 had single binocular vision after surgery, and 1 needed reoperation.

      Binocular vision and orthoptics investigation and management 1e pdf

      Of the 13 patients with a vertical deviation associated with a horizontal deviation, 9 had an associated exotropia Lyle and Foley, One of the 9 children with a vertical deviation associated with exotropia had no symptoms pre-operatively, but he did have a compensatory head posture. Four patients had a vertical deviation associated with esotropia Lyle and Foley, Two of these patients were symptomatic prior to surgery.

      Both symptomatic patients also had a compensatory head posture. Symptoms in one patient were relieved and head posture was normal after surgery. Single binocular vision was restored in the other patient after surgery, but the head posture remained abnormal. Two asymptomatic children with vertical deviations and esotropia also had a compensatory head posture; following surgery, both had single binocular vision and normal head postures.