HETEROPHORIA AND

VERGENCE
ABNORMALITIES
DR TEHREEM TANVEER
 HETEROPHORIA
• Heterophoria is defined as a latent tendency for
misalignment of the two eyes that become manifest only if
fusion between the eyes is dissociated.

• It is a latent strabismus in which the visual axis are

normally directed to the point of fixation but deviate when
the eyes are dissociated.
 CAUSES OF HETEROPHORIA
REFRACTIVE ERRORS
• Hypermetropia causes esophoria due to over accomodation leading to
over convergence
• Myopia causes exophoria due to less accomodation leading to less
convergence
• Oblique astigmatism may cause cyclophoria
ANATOMICAL FACTORS:
• Orbital assymetry
• Abnormal interpupillary distance
• Mild degree of extraocular ms weakness

PHYSIOLOGICAL FACTORS
• Role of accommodation
• Role of convergence
 TYPES OF HETEROPHORIA
• ESOPHORIA: Inward deviation
• EXOPHORIA: Outward deviation
• HYPERPHORIA: Upward deviation
• HYPOPHORIA: Downward deviation
• CYCLOPHORIA: Torsional deviation
COMPENSATED HETEROPHORIA:
• Controlled heterophoria with proper alignment of the eyes and no
symptoms as fusional amplitudes are sufficient to maintain alignment.
• Accounts for majority of the cases

DECOMPENSATED HETEROPHORIA:
• Clinically the pt presents with visual symptoms
• Fusional amplitudes are insufficient to maintain alignment
• Stress, fatigue, poor health, drugs affecting accomodation, alcohol
 SYMPTOMS
• Asthenopia
• Blurred vision
• Headache
• Diplopia
• Distorted images
• Difficulty in changing focus from near to far and vice versa
• Difficulty in stereopsis
 INVESTIGATIONS
• COVER-UNCOVER TEST
• MADDOX ROD TEST
• MADDOX WING TEST
• PRISM VERGENCE TEST
 TREATMENT
• Smaller degrees of heterophoria which give rise to no symptoms,
require no treatment.
• Appropriate refractive correction
• Orthoptic exercises- esp in convergence weakness exophoria
• Symptomatic relief with temporary stick on Fresnel prisms or
prisms incorporated in glasses.
• Surgery may occasionally be needed for larger deviations.
 VERGENCE
• A vergence is the simultaneous movement of both eyes in opposite
directions to maintain a binocular single vision.
• It permits stereopsis and prevents diplopia.
 VERGENCE ABNORMALITIES
Vergence abnormalities are disorders of binocular vision which result in either
a failure of fusion or an inability to sustain comfortable bifoveal fixation.

Examination of vergence abnormalities include measurement of

• Ocular alignment ( extra ocular movements)
• Near point of convergence
• Near point of accommodation
• Fusional amplitudes
• AC/A ratio
 NEAR POINT OF CONVERGENCE
• Nearest point on which eyes can maintain binocular fixation
• Measured with RAF rule
• Target moved closer until one eye losses fixation and drifts away.
• Normal NPC is 10cm. Not changed with age
 NEAR POINT OF ACCOMMODATION

• Nearest point on which eyes can maintain clear focus.

• Can also be measured with RAF rule.
• Focuses on a line of print until it gets blurred.
• NPA recedes with age.
• At 20 yrs – 8cm, 50 yrs – 46cm
 FUSIONAL AMPLITUDES/RESERVES

• Measures efficacy of vergence

movements
• Can be tested with verticle prism bars
or synoptophore.
• Prisms of increasing power are placed
infront of one eye until diplopia is
reported which indicates the limit of
fusional amplitude.
 ACCOMMODATIVE
CONVERGENCE/ACCOMMODATION RATIO

• Measurement of convergence induced per diopter of accommodation

• Normal range : 3-5 prism diopter/1 diopter of lens accommodation
• High AC/A ratio causes excessive convergence and convergent squint
during accomodation
• Low AC-A ratio causes divergent squint during accommodation.
• Can be measured with heterophoria or gradient method.
• HETEROPHORIA METHOD: measures ocular deviation for near
and far with full spectacle correction.

IPD in cm, n and d are ocular deviation for near and far in prism
diopters, D is near fixation distance in diopters.
• GRADIENT METHOD: uses a minus lens to induce
accommodation instead of near target.

• More accurate than heterophoria method.

• D is the power of minus lens used to induce accommodation
 CONVERGENCE INSUFFICIENCY
Reduced ability of the eyes to turn inwards on near work. Accommodation
insufficiency is occasionally also present. Typically affects school-going children
or individuals with excessive visual demand for near work.

Signs : diplopia, headache, blurred vision at near, reduced near point of

convergence and decreased fusional amplitudes.

Treatment : involves orthoptic exercises aimed at normalizing the near point

and fusional amplitudes . with good compliance , symptoms should be
eliminated within a few weeks but if persistent can be treated with base-in
prisms. For accommodation insufficiency minimum reading correction can be
prescribed.
 DIVERGENCE
INSUFFICIENCY
• Divergence paresis or paralysis is inability of the eyes to diverge. It is primarily a
concomitant esodeviation with reduced or absent divergence fusional
amplitudes.

• It is a rare condition usually associated with underlying neurological disease ,

such as intracranial space-occupying lesions, cerebrovascular accidents or head
trauma .

• Presentation may be at any age and is difficult to differentiate from sixth nerve
palsy.

• Difficult to treat ; prisms are the best option.

 NEAR REFLEX
INSUFFICIENCY
• TRIAD of near reflex: accommodation+ convergence+ miosis

• Paresis of the near reflex presents as dual convergence and

accommodation insufficiency. Mydriasis may be seen on attempted near
fixation. Treatment involves reading glasses , base-in prisms and possibly
botulinum toxin in lateral rectus . Orthoptic exercises have no effect.

• Complete paralysis in which no convergence or accommodation can be

initiated may be of functional origin, can be caused by midbrain disease
or follow by head trauma. Can be reversible.
 SPASM OF NEAR REFLEX
• Spasm of the near reflex is a functional condition affecting patients of all ages
(mainly females).

• Signs : diplopia , blurred vision and headaches accompanied by esotropia ,

pseudomyopia and miosis. Spasm may be triggered when testing ocular movements
. Observing miosis is the key to the diagnosis .Refraction with and without
cycloplegia confirms the pseudomyopia , which must not be corrected optically .

• Treatment involves reassurance and to discontinue any activity that triggers the
response . If persistent , atropine and a full reading correction are prescribed.
Patients usually seem to live a fairly normal life despite the signs and symptoms.
THANKYOU