BINOCULAR DYSFUNCTION REMEDIATION II

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BINOCULAR DYSFUNCTION REMEDIATION II

• VERGENCE THERAPY

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Vergence Dysfunctions

• Run along the horizontal axis of the new fangled,
  BVA O MATIC CHART
• Less severe towards center
• More severe towards periphery

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Vergence Dysfunctions

• Off horizontal axis increased accommodative
  involvement
• Lower
• Left PCI
• Right PCE (2º accommodative insufficiency)
• Upper PCE (2º to accommodative excess)

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AE
PCE 2ºAE
LOW/ NORMAL
HIGH/ NORMAL
CE
CI
LOW
HIGH
HIGH/ NORMAL
LOW/ NORMAL
PCI
PCE 2ºAI
AI
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Convergence Insufficiency

• More severe at left edge
• Anti-suppression and accommodation are secondary
  modalities to address
• 3-4 vergence/1-2 anti-suppression activities
  first 1-3 sessions
• Incorporate 2 accommodative activities after 4th
  session

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Convergence Excess

• More severe at right edge
• Usually expect smaller gains each week of Tx
  compared with insufficiency
• Accommodation is a secondary modality to address
• 5 vergence activities first 2-3sessions
• Incorporate 2 accommodative activities after 3rd
  session

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Pseudo CIs

• Spread out, away from the horizontal axis
• Bottom left Classic Pseudo CI
• Usually requires 2.5 activities of Accomm. and
  vergence throughout Tx!
• Closely monitor for A/S problems
• Takes longer to remediate than other vergence Dx

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Pseudo CE Secondary to Accommodative Insufficiency

• Spread out, away from the horizontal axis
• Bottom right Pseudo CE 2º AI
• Usually requires an initial add
• may be enough to remediate problem
• 3 accommodative activities /2 vergence activities

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Pseudo CE Secondary to Accommodative Excess

• Spread out, away from the horizontal axis
• Top right Pseudo CE 2º AE
• Accommodative excess is usually the most dramatic
  feature here
• Rarely above 2-3 prism diopters esophoria at near
• Accommodative facility (relaxation) significantly
  affected
• 3 accommodative activities/2 vergence expected

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General Approach for Vergence Dysfunction

• Rock a patient from something they can
  accomplish with ease to something difficult
• This mantra of BV is still applied at the end of
  therapy (i.e. begin integrated convergence work
  with minus and BI).

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General Approach for Vergence Dysfunction
Vergence Starting Point

• Vergence activities usually begun at the
  transitional level
• At times, very basic walk-towards/away therapy
  is necessary for several sessions

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General Approach for Vergence Dysfunction
Accommodative Technique Starting Point

• A vergence patient with normal skills
• Will have difficulty controlling and adjusting
  vergence output with binocular level techniques
• Would not be able to maintain vergence at a
  steady state on binocular accommmodative rock
• In many cases, only 2-3 sessions at the
  trasitional level for vergence skills is required.

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General Approach for Vergence Dysfunction
Anti-Suppression Starting Point

• Necessary if your therapy grinds to a halt
  because of suppression
• May occur at either the transitional or binocular
  level, for any modality.

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General Approach for Vergence Dysfunction
Anti-Suppression Starting Point

• Blinking, flashing a penlight at the suppressing
  eye or tapping the target being suppressed may be
  all that is required
• When suppression is still preventing progress,
  the following activities would be called for

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Anti-Suppression Activities

• Transitional
• Vis-a-vis
• Red/red rock without dioptric lenses
• Doells Mazes or Litetrac series
• Brock BU series/Morgenstern Basic Fusion cards
• Binocular
• Cheiroscopic tracings
• AN and EC series

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General Approach for Vergence Dysfunction
Oculomotor Starting Point

• Oculomotility skills may be affected in children
  with vergence dysfunction.
• A relatively high correlation exists between true
  convergence insufficiency and oculomotor
  dysfunction.
• When necessary, one (out of 5) activity in the
  orthoptics session will be OM

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Cases True CI (case ............)

• Vergence dysfunction
• Bad combination of
• Low AC/A ration
• Insufficient compensating vergence ranges (BO)
• DDx from Psuedo CI includes
• Difficulty w/ on binocular accomm. Facility
• No trouble w/ monocular
• No plus acceptance/low lag/lead of accommodation

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Cases Pseudo CI (case ..........)

• Accommodation dysfunction w/ vergence
  side-effects
• Bad combination of
• Poor accommodative control
• debilitated vergence ranges (BO) gives up the
  nearpoint ship

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Cases Pseudo CI (case ..........) Cont.

• DDx from true CI includes
• Difficulty clearing MINUS on monocular and
  binocular /-2.00 facility
• May have difficulty with plus binoc. facility (if
  PRC is low enough)
• Plus acceptance/high lag
• some improvement with plus