Vertical & Cyclo Deviations

1. benign

2. CN 4 palsy

3. CN 3 palsy

4. lesions of MLF

5. neurodegenerative diseases

6. trauma

what are some potential causes of a vertical deviation?

cyclodeviation

torsion of the eye around the line of sight

convergence, upgaze

cyclodeviations increase w/ ________

astigmatic axis

cyclodeviations can cause ______ at near

inferior oblique

cyclodeviation increases at near are likely due to ______ innervation w/ convergence

R hyper

what is being described in this CT scenario?

1. fusion and alignment prior to dissociation

2. R eye deviates upward under the cover paddle

3. R eye picks up fixation as cover paddle is moved to L eye, able to observe R eye move downward

4. L eye deviates downward under cover paddle

hyper

for a vertical phoria, you label the ______ eye

strabismic (hyper OR hypo)

for a vertical tropia, you label the ______ eye

hyper

if a vertical tropia is alternating, label the ______ eye

1. losing place when reading

2. skipping lines when reading

3. pulling sensation

4. asthenopia

5. HA

6. near blur

7. diplopia

8. car sickness

9. dizziness

10. tilting of objects

11. heat tilt

12. facial asymmetry

what are some potential sx/signs for a vertical or cyclo deviation?

Maddox rod

gold standard for testing vertical deviations?

CT, Von graefe, maddox rod, modified thorington, saladin card

what are the options for dissociated phoria testing?

traditional, modified thorington, saladin card

what are the 3 versions of the maddox rod?

horizontal

when doing lateral deviation testing w/ Maddox rod, how should the striations be oriented?

R

which eye sees the streak on Maddox rod if it is held over the R eye?

L

which eye sees the spot of light if the Maddox rod is held over the R eye?

eso

if the Maddox rod is held over the R eye & the pt reports that the red streak is to the right of the light, they have a ____ deviation

exo

if the Maddox rod is held over the R eye & the pt reports that the red streak is to the left of the light, they have a ____ deviation

R hyper

if the Maddox rod is held over the R eye & the pt reports that the red streak is below the light, they have a ____ deviation

loose prism

how is magnitude of a deviation determined w/ the Maddox Rod test?

no

is Maddox rod good for lateral deviation testing?

poor accommodation control

why is Maddox rod not good for lateral deviation testing?

eso

distance lateral phoria tends to be too much ____ w/ Maddox Rod testing

exo

near lateral phoria tends to be too much ____ w/ Maddox Rod testing

1. objective measure

2. can differentiate strab vs phoria

3. great accommodation control

what are the advantages of cover test?

can be hard to see small vertical deviations

what are the disadvantages of cover test?

cover test

what is the best test for lateral deviations?

1. reasonable accommodative control

2. distance & near testing available

3. convenient to perform post new refraction

what are the advantages of Von Graefe?

1. subjective

2. phoropter eliminates peripheral fusion

3. phoropter induces proximal convergence

4. frequently elicits false verticals

5. overestimates magnitude of a lateral phoria

what are the disadvantages of Von Graefe?

1. very accurate for vertical

2. useful for comitancy evals

3. distance & near testing available

what are the advantages of Maddox Rod?

1. poor accommodative control

2. subjective

3. can be hard to test at distance w/o a tech

4. inaccurate lateral phoria data

what are the disadvantages of Maddox rod?

1. distance & near testing available

2. don’t have to fumble w/ prism

3. can test distance easily as a solo clinician

what are the advantages of Modified Thorington?

1. poor accommodative control

2. subjective

3. occasionally elicits false verticals

4. inaccurate lateral phoria measure

what are the disadvantages of Modified Thorington?

1. reasonable accommodative control

2. no fumbling w/ prism

what are the advantages of Saladin card?

1. subjective

2. no distance test available

3. occasionally elicits false verticals

4. inaccurate lateral phoria data

what are the disadvantages of Saladin card?

BD

with the double Maddox rod test, the image that appears to be up is coming from the eye with the ____ prism

primary

vertical deviation exists whether the patient is aligned or strabismic, consider treating the vertical w/ prism as it may help the pt maintain better alignment

secondary

vertical deviation exists only when the patient is misaligned, common in IXT, treat the horizontal deviation first to limit the amount of time the pt is misaligned

no

do you treat the vertical deviation with prism with a secondary vertical deviation?

larger

on CT, if there is a horizontal & vertical deviation, you should neutralize the ______ magnitude one first to determine if the other deviation is still present or to better view it

prism

what is the best option for tx of vertical deviation?

no

can you use lenses to tx vertical prism?

limited effectivity

VT has ___________ for treating vertical deviations

Rx 1/3 of vertical

Hansel & Reber method for prescribing prism for vertical deviations

Rx 2/3 of vertical

Emsley & Maddox method for prescribing prism for vertical deviations

Rx ¾ of the vertical

Giles method for prescribing prism for vertical deviations

Rx full amount if small (1.5^ or less)

other method for prescribing prism for vertical deviations

evaluate each case individually and Rx the weakest prism that relives sx & restores binocularity

Krimsky method for prescribing prism for vertical deviations

yes

is the vertical associated phoria effective for prescribing vertical prism?

1. can assist in prescribing prism

2. can predict magnitude & direction of vertical phoria based upon balance of vertical break values

3. can determine if a deviation is chronic or acute

what are the uses of vertical vergence ranges?

(BD to break - BU to break)/2

predicted vertical phoria or amount to Rx =

BD

you solve the (BD to break - BU to break)/2 equation & get a positive answer. this tells you the pt needs _____ prism

BU

you solve the (BD to break - BU to break)/2 equation & get a negative answer. this tells you the pt needs _____ prism

1. speed at which prism is introduced

2. distance at which measurement is taken

3. residual tonicity

4. chronic vs acute conditions

vertical vergence ranges often vary due to:

prediction of the longevity of vertical deviation

what is the most important clinical use of vertical vergence ranges?

compensation (larger vertical range)

congenital or longstanding vertical deviations will have _________

1. measure the amount of dissociated vertical phoria

2. obtain tentative prism using one of the methods

3. trial the prism (be sure to check for placebo effect)

4. consider checking binocular function w/ prism in place

what are the steps for determination of a final prism rx?

1. age

2. head posture

3. sx

4. magnitude of deviation

5. level of compensation

6. presence of other BV sx or learning/reading issues

what are some things to consider when deciding to prescribe vertical prism or not?

1pd or less

you should put all of the prism in one lens if it is ______

split equally b/t lenses

if the deviation is non-paralytic, how should you split the prism?

unequally (paretic eye will need more)

how should you split the prism if the deviation is paralytic?

slab off/on

you should consider ____ if vertical prism is only needed at distance or near

0.50-1^

consider prism ballasted toric CLs for _______ of prism

4^

consider custom prism soft lenses for up to _____ of vertical deviation