Case 5 ILOs

1. How can we differentiate between true double vision and distortion caused by
astigmatism? (What are the tests or history questions we can ask)

True Diplopia is the deterioration of the fusional capacity present in a binocular system
whereby the neuromuscular coordination is unable to merge two visual objects on the foveae
of both eyes.
- Occurs due to the image point lying out of the fovea in one eye creating 2
distinct images; strabismus
- Diplopia is horizontal if the eye alignment is horizontal

Monocular Diplopia can be caused from irregular transmission of light into the eye.
Examples of such cases include:
- Corneal distortion, corneal scarring, polycoria (multiple pupils in iris), cataract,
abnormalities in the vitreous, conditions of the retina.
- most commonly caused by an Ophthalmological issue including cataracts,
keratoconus, and uncorrected astigmatism
- Use PH to determine if it is monocular; Diplopia should diminish when viewing
through a PH aperture
- If visual field test shows homonymous defects, and PHNI, monocular Diplopia
is functional

https://emedicine.medscape.com/article/1214490-overview#a4
https://www.ncbi.nlm.nih.gov/books/NBK441905/
https://nyulangone.org/conditions/double-vision/diagnosis

Case History Questions

Question Indication
When you look at objects, is the image Metamorphopsia
wavy or warped?
Do you experience flashes or coloured Retinal lesion
lights in your vision?
Do colours in your vision appear washed Nerve dysfunction
out or faded?
Monocular or binocular? If Diplopia still occurs after occluding one
eye = monocular Diplopia

If Diplopia vanishes after occluding one eye

= deterioration in the binocularity of BE

Onset? Sudden = vascular origin

Gradual = slow tumour developing, or
neurological disorder

Direction of DV? Is it vertical or horizontal? Specific directions of DV can suggest

deterioration in a particular EOM

Neurological disorders tend to result in

vertical DV

Have you had past experiences of DV Determine if they have had astigmatism
before? earlier
How is your GH? Any past surgeries? History of brain stem strokes, neurological
conditions, cataracts that could contribute
 to distorted V or acquired astigmatism
https://www.racgp.org.au/getattachment/5ec7ae60-ea45-4837-9d16-eb9310944b07/
attachment.aspx

Tests for True Diplopia and Metamorphopsia caused by astigmatism

Test
Ocular Motility Test
Alternate Cover Test
Procedure
Double H. A visual target
such as the tip of a pen is
slowly moved in all 6
directions of gaze in each
eye, and the px is instructed
to eye the target
continuously throughout
Cover one eye and observe Indenting if tropia or phoria
the un-occluded eye for
movement
Then repeat but alternate
occluding each eye and
observe for movement
Justification
Identify clear signs of EOM
dysfunction and deficits,
signs indicating dysfunction
in CN3 or CN6
is present.
No movement, Px has a
phoria, both eyes remained
fixated on the target
Movement, Px has tropia

One eye occluded should

resolve condition for
binocular Diplopia. One eye
occluded may have no
improvement.

Pupillary exam Observe movement of

pupils. Pen torch
examination

Lid exam Observe positioning of lids

and movement during ocular
motility test

Dilated fundus exam
Mydriatic eye drop is applied
onto Px eyes and then an
image of their retina is taken
with the fundoscopy
machine
Determine if the optic nerve
head shows signs of
Oedema and venous status
retinopathy

PH V with PH PH should improve if

monocular Diplopia.

PHNI if True Diplopia

Keratometry Use keratometer Pentacam Determine steepness of

to capture a photograph corneal meridians and
mapping the surface of the observe for signs of
cornea of the Px astigmatism

https://www.optometrystudents.com/the-anatomy-of-the-cover-test/
https://www.ncbi.nlm.nih.gov/books/NBK441905/

Management of Diplopia
Fresnel prisms can be attached onto px spectacles to realign two images, and will need to
be adjusted accordingly as the px’s vision improves. If the px is struggling with the prisms,
the Diplopic eye can be occluded to remove the DV however it will cause a major reduction
of depth perception. Operating monocularly can be dangerous when travelling along stairs
and driving. Moreover, according to VicRoads, the px would require an assessment and
diagnosis of a monocular condition for 3 months before they are allowed to drive
monocularly, and their vision must be at least 6/12 with a horizontal visual field of 140
degrees, whereby they may apply for a conditional drivers license.
Acquired palsies can improve naturally so it is recommended not to surgically treat a px
unless their condition is stable or the muscle function has been deemed as permanently
reduced for 12 months. Surgery should be the last treatment option considered.
https://www.researchgate.net/publication/347421077_History_of_Astigmatism_Diagnostics
https://www.optometry.org.au/wp-content/uploads/States/VIC/OVSA-Driving-Standards-for-
Vision-digital-desktop-print_v10.pdf

https://austroads.com.au/publications/assessing-fitness-to-drive/ap-g56/vision-and-eye-
disorders/general-assessment-and-management-guidelines
https://glaucoma.org.au/i-have-glaucoma/living-with-glaucoma/driving-and-glaucoma

2. What is stereopsis? definition? (tests (RANDOT), treatment/management,

implications for poor stereopsis in a table) - 3 columns

Stereopsis is the perception of depth that occurs from viewing with binocular
disparity. It allows for the perception of binocular cues that produces a 3D image
when the two images from both eyes are combined. This mechanism is known as
stereopsis. It can be used to determine the presence of deficits in early visual
processing caused by damage in the magnocellular or parvocellular visual pathways.

Stereopsis is quantitatively measured by stereo threshold or stereoacuity; ‘the

smallest depth interval between two stimuli that a subject can detect using only
stereoscopic cues’

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442860/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4050980/

Tests Management Implic

ations
Rand Px selects the circle that Stereopsis may be partially recovered Poor
ot appears closer to them through vision therapy Whereby a perce
training ‘paradigm’ that uses ption
https:// monocular cues and disparity cues. Px of
www.stereooptical.com/wp- are trained through perceptual learning depth
content/uploads/2018/01/LEA- where they perform visual tasks and
symbols-FLY-2017-User- repetitively. This is useful in may
manual-ONLY-12212017-2.pdf neurotypical px. not be
For Stereo deficient px, binocular able
Rand training through videogames have to
ot been applied. (However, good results drive.
Presc in lab, poor results in RCT) Poor
hool judge
https://www.ncbi.nlm.nih.gov/pmc/ ment
articles/PMC3174650/ at
how
https://www.sciencedirect.com/ far
science/article/pii/ apart
S0042698922000888 differe
https:// nt
www.stereooptical.com/wp- object
content/uploads/2017/10/ s are
Randot-Preschool_09-07- relativ
2017.pdf e to
each
Howa Measures the number of errors other
rd- a px makes at any distance
Dolm when determining the distance
an between 2 rods. A scale in
minutes of arc is used and
provides the amount of error in
mm. The px is positioned at 6m
while one peg remains
stationary and the other peg is
moved until it can be detected
by the px

https://www.bernell.com/
product/HDTEST/126

Titmu Stereogram where the px is

s instructed to pinch the Wings
circles of the fly. Clinician observes if
/Wirt the px fingers remain above
fly the plane of the image.
test
https://
www.stereooptical.com/wp-
content/uploads/2018/01/LEA-
symbols-FLY-2017-User-
manual-ONLY-12212017-2.pdf

ASTE Digital stereogram Interactive

ROID game on an ‘auto stereoscopic
stereo Tablet computer’
test Uses an adaptive staircase
adjustment of the target and
measures over 20 responses
where the px selects which
pattern of disparate dots
appears to float.
 https://onlinelibrary.wiley.com/
doi/10.1111/opo.12737

https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC7442860/
https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC6396686/

Study published in 2020 found ASTEROID to be the best clinical tool for measuring
baseline stereopsis as well as measuring progression throughout treatment for
amblyopia and strabismus in comparison to Randot circles, and Randot Preschool

ASTEROID was able to measure a wider range of stereo threshold, was determined
highly accurate and has a fair test-retest reliability

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442860/

3. What are the differences between monocular and binocular double vision?
(definition, causes, tests to differentiate) - make a table :)

Monocular DV
Definition
Monocular Diplopia can be
caused from irregular
transmission of light into the
eye, and only occurs in one
eye
Causes
Corneal distortion, corneal
scarring, polycoria (multiple
pupils in iris), cataract,
abnormalities in the
vitreous, conditions of the
retina, keratoconus, and
uncorrected astigmatism
Tests
PH, alternative cover test,
visual field test, keratometry,
V Exam
May not resolve when one
eye is closed

Binocular DV
Definition
True Diplopia is the
deterioration of the fusional
capacity present in a
binocular system whereby
the neuromuscular
coordination is unable to
merge two visual objects on
the foveae of both eyes.
Causes Tests
Cortical lesions, PH, alternative cover test,
deterioration in medial or visual field test, keratometry,
lateral rectus muscles, V exam
damage of the
neuromuscular junction, When one eye closes, it is
damage to nerves supplying resolved
EOMs (CN3/CN6), sixth
nerve palsy (if DV is worse
because of divergence
difficulty), medial rectus
palsy (if worse at NV
 because difficulty
converging)

https://eyewiki.aao.org/Basic_Approach_to_Diplopia

4. What tests are available for subjectively determining the power and axis of the
cylindrical component of an astigmatic refraction? How is this fit into
performing a subjective refractive test?

Test Description
Astigmatic fan and block technique Used when the px is unable to respond well
/Maddox V test to cross-cyl test

A range of radiating lines are spaced with

increments of 10 deg and organised into a
sun-ray pattern. A V and 2 sets of lines
90deg apart from each other (called blocks)
are formed. The clinician is able to move
the V and block at the same time at 180deg

Performed after BVS

Astigmatic clock dial and fogging technique 1. VA determined with one eye
occluded and the other eye has sph
lenses placed in front of it.

2. The eye is made compound myopic

astigmatism with a plus sph to relax
accommodation

3. Px instructed to fixate on the

astigmatic dial and judge where the
‘darkest and sharpest lines’ lie

4. Minus lenses are applied on the axis

90deg to the black and sharp lines
until the px see the lines appearing
equal. The rotating cross dial is used
to align the principal meridians

5. D chart used and reduce plus sph

until the px reports clear V

Jackson cross cylinder technique
Combines 2 cyl lenses of equal power with
opposite signs set on a handle at right
angels. (+/- 0.25 or +/- 0.50 commonly
used). Purpose of this test is to refine the
cyl axis

Performed as final part of subj Rx

https://www.ncbi.nlm.nih.gov/books/NBK580482/
 5. What are the limitations for some patients being unable to achieve a visual
acuity greater than 6/6? (Pathological? Genetic? Physiological?)

- Slight refractive error

- Slight Astigmatism
- Cataracts
- Keratoconus

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688402/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020211/

Pupil size, resolution

Cone diameter (bigger, less fit in fovea, resolve lower)
Cone spacing

Functional visual field loss, organic visual field loss; conversion disorder

6. When is +cyl notation useful? What are the positives and negatives of -cyl and
+cyl notation?

Positive cyl is used by opthalmologists as it is useful when planning surgical

treatment since incisions applied onto a plus axis will reduce astigmatism, it is more
efficient for them to use positive cyl notation rather than negative cyl notation.

Negative cyl notation is better for refractive surgery since most optometrists use
negative cyl hence this is better when prescribing spectacles

Less meridianal magnification, toric lenses

Accommodation, ophthal can use cycloplegics, optom cannot

https://opticiannow.com/2018/09/19/why-do-optometrists-write-rxs-in-negative-
cylinder-while-ophthalmologists-use-positive-cylinder/

7. What are the management options for astigmatism? What are the different
types?

Type of Astigmatism Description Management

(Treatment/post-
operative
care/rehabilitation)
Axis
WTR Vertical meridian is steeper than Horizontal Minus cyl along
horizontal meridian for
correction

ATR Horizontal meridian is steeper than Vertical Minus cyl along vertical
meridian for correction
Oblique Oblique meridian is steeper than Vertical Minus cyl along oblique
meridian meridian for correction
 Focal lines

Simple Simple myopic

= one focal line positioned in front of retina,
other positioned at retina

Simple hyperopic
= one focal line positioned behind retina,
other positioned at retina

Compound Compound myopic

= both focal lines positioned in front of retina

Compound hyperopic
= both focal lines positioned behind retina

Mixed One focal line is positioned behind the retina

and the other is positioned in front of the
retina

Regularity
Regular Principal meridians perpendicular Corrected with cyl lenses
Irregular Principal meridians are not perpendicular, Cannot be corrected well
there is a significant asymmetry in curvature with cyl lenses
of both meridians
Needs rigid GP CL for best
VA

(E.g. keratoconus)

https://www.ncbi.nlm.nih.gov/books/NBK582142/

Factors impacting astigmatism

- Eyelid pressure
- EOM pressure
- Size of pupil
- Accommodation

Astigmatism tests
Test Description Indication
VA examination With PH Help determine BCVA
Retinoscopy Examines the axis and amount Scissor reflex indicates

Slit lamp evaluation
examination (Orbscan)
Keratometry
Schiempflug imaging
Pachymetry
Jackson cross-cylinder
https://www.ncbi.nlm.nih.gov/books/NBK582142/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5766020/
How prism lenses correct astigmatism
of astigmatism
A scanning slit method is used
whereby bands of light are
projected across the cornea.
An attached camera will
capture the beams reflecting
off the cornea and form map
of the corneal surface
anteriorly and posteriorly
Pentacam captures mapping of
the corneal surface
A camera utilising Schiempflug
technology produces
topographic reports
Examines the thickness of the
cornea
Refines results for refractive
power and axis of of the cyl
keratoconus, can show
different powers of the two
meridians
Examine the steepness of the
cornea
Steepness of meridians are
demonstrated. If vertical more
steep than horizontal then it
indicates a WTR astigmatism
etc
Determines regularity of
astigmatism
Steepness of cornea
Indicates if the px eye is
suitable for surgery. Cannot be
too thin
-PRK for thin corneas
Refines amount of cyl
required/amount of
astigmatism