8 - non-strab conditions: DI, DE, CE

What are the common symptoms of divergence insufficiency?

1. strain, blur, diplopia with distance tasks

2. symptoms worsen throughout day

3. car sickness

4. difficulty driving or watching TV

5. difficulty focusing from far to near

What are the signs of divergence insufficiency?

1. greater esophoria at distance with greater frequency

2. decreased NFV at distance

3. eso fixation disparity at distance

4. comitant deviation

What is the differentia diagnosis for divergence insufficiency?

1. basic esophoria

2. convergence excess

3. hyperopia

4. pathology

What is the treatment for divergence insufficiency?

1. prescribe for refractive error (esp hyperopia)

2. BO prism

3. therapy (not really)

What are the common symptoms of a basic exo?

1. intermittent diplopia at distance and near

2. strain with distance and near tasks

What are the signs of basic exo?

1. equal amounts (within 5pd) of exo at distance and near

2. PFV not adequate for phoria

3. receded NPC

4. reduced binoc accommodation facility with plus

5. low NRA

6. plano or lead of accommodation

7. vertical deviation

8. exo fixation disparity at distance and near

what fixation disparity curve is basic exodeviation?

type III fixation disparity

What is the differential diagnosis for basic exo?

1. convergence insufficiency

2. divergence excess

3. underlying pathology

What is the treatment for a basic exo?

1. correct RE

2. (#1) therapy

3. vertical or horizontal prism

What are the common symptoms of a basic eso?

1. strain with near and distance tasks

2. headaches/difficulty concentrating with near work

What are the signs of a basic eso?

1. equal amounts of eso at distance and near (within 5pd)

2. low NFV at distance and near

3. low PRA

4. reduced binoc accommodation facility with minus

5. high lag (may conceal eso)

6. eso fixation disparity and distance and near

7. vertical deviation

8. hyperopia

what fixation disparity is eso deviation?

type II fixation disparity curve

What is the differential diagnosis for basic eso?

1. divergence insufficiency

2. convergence excess

3. pathology

What is the treatment for basic eso?

1. prescribe full plus

2. BO horizontal or vertical prism

3. therapy

4. added lenses if near symptoms only

What are the common symptoms of fusional vergence dysfunction?

inability to concentrate at near

slow reading, decreased reading comprehension

What are the common signs of fusional vergence dysfunction?

1. orthophoria or small phoria at distance and near

2. decreased vergence facility

3. decreased vergence ranges at distance and near

4. may have decreased NRA/PRA

5. reduced binocular accommodation facility (plus and minus), but normal monoc

What is the differential diagnosis for fusional vergence dysfunction?

1. accommodative infacility

2. latent hyperopia

3. vertical or cyclodeviation

4. fixation disparity

5. aniseikonia

6. underlying disease

What is the treatment for fusional vergence dysfunction?

1. therapy

2. prism

3. surgery

What are the common symptoms of convergence excess?

1. higher scores on CISS

2. problems at near, occasionally distance if significant distance phoria present

3. often longstanding/chronic

What are the signs of convergence excess?

1. greater esophoria at near

2. decreased NFV at near

3. high lag of accommodation (may conceal some eso)

4. low PRA

5. intermittent suppression

6. reduced binoc accom facility with minus

7. eso fixation disparity at near

8. may have vertical deviation

9. can decompensate to strabismus

Which sign in convergence excess are common in patients with the worst symptoms?

high lag of accommodation

What is the differential diagnosis of convergence excess?

1. basic esophoria

2. divergence insufficiency

3. accommodative disorders

4. hyperopia

5. spasm of accommodation

6. underlying pathology

What is the treatment for convergence excess?

1. correct RE (cyclo)

2. plus lens at near

3. therapy

4. BO prism if eso at distance and near

How does divergence excess frequently present?

intermittent strab at distance

What triggers divergence excess to manifest as a strab?

1. inattention, fatigue, daydreaming

2. illness

What is simulated DE?

basic exo patient who has good proximal fusion, therefore looks less exo at near

How do you distinguish between a true DE vs simulated DE?

≥30 min occlusion

if true DE: no difference in exo after occlusion

if simulated DE: exo at near will increase to similarly match distance

What are the common symptoms of divergence excess?

1. reports of one eye turning out

2. possible diplopia

3. asthenopia

4. photophobia

What are the signs of divergence excess?

1. greater exo at distance than near (magnitude and frequency)

2. comitant deviation

3. suppression +/or HAC at distance if strab present (will have no diplopia)

4. normal NPC

5. inadequate PFV for deviation

6. inadequate NFV

7. eso fixation disparity at near

8. may have IO overreaction

9. high stimulus AC/A but normal to high response AC/A

What is the differential diagnosis for divergence excess?

1. basic exophoria

2. simulated divergence excess

3. convergence insufficiency

What is the treatment for DE?

1. therapy

2. added minus

3. surgery

What are bad prognostic factors for DE?

1. large deviation

2. large vertical deviation

3. noncomitancy

What are the common symptoms of a vertical phoria?

1. frequent loss of place when reading

2. motion sickness

3. difficulty attending/concentrating during sustained visual tasks

4. diplopia

5. blurred vision

What are common signs of a vertical phoria?

1. head tilt

2. decreased horizontal fusion ranges

3. vertical fusion ranges may be decreased or exceptionally large

What are the associated conditions with vertical phoria?

1. dyslexia

2. learning disability

What are the causes of a vertical phoria?

1. hyperorbit

2. improper EOM insertion

3. secondary to lens extraction (pseudophakes)

4. CN palsies

5. skew deviation

6. myasthenia

7. muscle overaction

What is the treatment for vertical phoria?

1. prism (for symptomatic patients with 0.75pd or more)

2. vertical fusion therapy (hard)