Diagnostic validity of clinical signs associated with a large exophoria at near

Purpose. To analyze the diagnostic validity of accommodative and binocular tests in a sample of patients with a large near exophoria with moderate to severe symptoms. Methods. Two groups of patients between 19 and 35 years were recruited from a university clinic: 33 subjects with large exophoria at near vision and moderate or high visual discomfort and 33 patients with normal heterophoria and low visual discomfort. Visual discomfort was defined using the Conlon survey. A refractive exam and an exhaustive evaluation of accommodation and vergence were assessed. Diagnostic validity by means of receiver operator characteristic (ROC) curves, sensitivity (S), specificity (Sp), and positive and negative likelihood ratios (LR+, LR−) were assessed. This analysis was also carried out considering multiple tests as serial testing strategy. Results. ROC analysis showed the best diagnostic accuracy for receded near point of convergence (NPC) recovery (area = 0.929) and binocular accommodative facility (BAF) (area = 0.886). Using the cut-offs obtained with ROC analysis, the best diagnostic validity was obtained for the combination of NPC recovery and BAF (S  =  0.77, Sp = 1, LR+ = value tending to infinity, LR− = 0.23) and the combination of NPC break and recovery with BAF (S  =  0.73, Sp = 1, LR+ = tending to infinity, LR− = 0.27). Conclusions. NPC and BAF tests were the tests with the best diagnostic accuracy for subjects with large near exophoria and moderate to severe symptoms.

Screening for convergence insufficiency using the CISS is not indicated in young adults

Aim This paper presents Convergence Insufficiency Symptom Survey (CISS) and orthoptic findings in a sample of typical young adults who considered themselves to have normal eyesight apart from weak spectacles. Methods The CISS questionnaire was administered,followed by a full orthoptic evaluation, to 167 university undergraduate and postgraduate students during the recruitment phase of another study. The primary criterion for recruitment to this study was that participants‘feltthey had normal eyesight'. A CISS score of ≥21 was used to define‘significant’symptoms, and convergence insufficiency (CI) was defined as convergence≥8cm from the nose with a fusion range <15Δ base-out with small or no exophoria. Results The group mean CISS score was 15.4. In all, 17(10%) of the participants were diagnosed with CI, but 11(65%) of these did not have significant symptoms. 41(25%) participants returned a‘high’CISS score of ≥21 but only 6 (15%) of these had genuine CI. Sensitivity of the CISS to detect CI in this asymptomatic sample was 38%; specificity 77%; positive predictive value 15%; and negative predictive value 92%. The area under a receiver operating characteristic curve was 0.596 (95% CI 0.46 to 0.73). Conclusions‘Visual symptoms’are common in young adults, but often not related to any clinical defect, while true CI may be asymptomatic. This study suggests that screening for CI is not indicated

Reading performance is not affected by a prism induced increase of horizontal and vertical vergence demand

PURPOSE Dyslexia is the most common developmental reading disorder that affects language skills. Latent strabismus (heterophoria) has been suspected to be causally involved. Even though phoria correction in dyslexic children is commonly applied, the evidence in support of a benefit is poor. In order to provide experimental evidence on this issue, we simulated phoria in healthy readers by modifying the vergence tone required to maintain binocular alignment. METHODS Vergence tone was altered with prisms that were placed in front of one eye in 16 healthy subjects to induce exophoria, esophoria, or vertical phoria. Subjects were to read one paragraph for each condition, from which reading speed was determined. Text comprehension was tested with a forced multiple choice test. Eye movements were recorded during reading and subsequently analyzed for saccadic amplitudes, saccades per 10 letters, percentage of regressive (backward) saccades, average fixation duration, first fixation duration on a word, and gaze duration. RESULTS Acute change of horizontal and vertical vergence tone does neither significantly affect reading performance nor reading associated eye movements. CONCLUSION Prisms in healthy subjects fail to induce a significant change of reading performance. This finding is not compatible with a role of phoria in dyslexia. Our results contrast the proposal for correcting small angle heterophorias in dyslexic children.

Type of strabismus and changes to fusion measures

Assessing the range of vergence provides information about the patient’s ability to maintain the binocular vision. Disparity vergence measurements should be used to quantify control of an underlying eye misalignment. In the presence of a manifest deviation the testing is performed by first compensating the angle of deviation to determine prognosis. Type of deviation: a) in an exophoria there is an increase in the fast fusional convergence while in an esophoric deviation there is an increase in reflex fusional divergence to attain binocular single vision; b) convergence fusion amplitudes have been found to correlate with control of the exodeviation; c) there is a greater BO range for esos and greater BI range for exos.

Fusional vergence measurements for eso versus exo deviations: is there a difference?

Purpose: The aims of this study were to compare angle of deviation, fusional vergence measurements and fusion reserve ratio between esophoria and exophoria. Methods: A cross-sectional study was performed in children with best-corrected visual acuity of 0.0 LogMAR in either eye, compensated heterophoria within 10 prism dioptres (PD), full ocular rotations, presence of fusional vergence and stereopsis (60 seconds of arc or better). Fusional amplitudes were compared between angle of deviation (2, 4, 6, 8 and 10 PD) in esophoria and exophoria. The fusion reserve ratio was calculated (to assess the effect of the underlying angle of deviation) as fusional convergence divided by prism alternating cover test measurements. Results: Two-hundred and eleven children (7.65±1.16 years) were recruited to this study. Exophoria was most common for near (n=181; 85.8%) and distance (n=20; 9.5%). Esophoria was present in 22 children for near (10.4%) and in 1 child for distance (0.5%). No significant differences were found between fusional amplitudes and angle of deviation for near (p>0.05). Children with exophoria of 10PD had a slight, but not, significant (p=0.264) increase in fusional convergence from 2PD (19.95±5.09) to 10PD (26.67±5.77). In esophoric children the variation of fusional convergence was smaller from 2P (25.00±0.00) to 10PD (22.50±3.54) and non significant (p=0.185). The fusion reserve ratio was significantly smaller in children with higher deviations (i.e. 10PD) for both esophoria (p=0.003) and exophoria (p>0.001). The fusion reserve ratio ranged between 12.50 (2PD) and 2.25±0.35 (10PD) for esophoria and between 9.98±2.55 (2PD) and 2.67±0.58 (10PD) for exophoria. Conclusions: Angle of deviation is not an efficient measure to predict fusional amplitudes. The fusion reserve ratio appears to be a better measurement to assess the effect of the underlying angle of deviation on fusional convergence. More studies are necessary to understand better the relationship between fusion amplitudes and angle of deviation.