1. BINOCULAR DYSFUNCTION REMEDIATION II VERGENCE THERAPY

2. Vergence Dysfunctions Run along the horizontal axis of the new fangled, BVA ‘O’ MATIC CHART Less severe: towards center More severe: towards periphery

3. PCE 2ºAE PCE 2ºAI CE AI AE PCI CI LOW HIGH LOW/ NORMAL HIGH/ NORMAL HIGH/ NORMAL LOW/ NORMAL

4. Vergence Dysfunctions Off horizontal axis: increased accommodative involvement –Lower: Left: PCI Right: PCE (2º accommodative insufficiency) –Upper: PCE (2º to accommodative excess)

5. PCE 2ºAE PCE 2ºAI CE AI AE PCI CI LOW HIGH LOW/ NORMAL HIGH/ NORMAL HIGH/ NORMAL LOW/ NORMAL

6. Convergence Insufficiency More severe at left edge Anti-suppression and accommodation are secondary modalities to address 3-4 vergence/1-2 anti-suppression activities first 1-3 sessions Incorporate 2 accommodative activities after 4th session

7. Convergence Excess More severe at right edge Usually expect smaller “gains” each week of Tx compared with insufficiency Accommodation is a secondary modality to address 5 vergence activities first 2-3sessions Incorporate 2 accommodative activities after 3rd session

8. Pseudo CI’s Spread out, away from the horizontal axis –Bottom left: “Classic” Pseudo CI Usually requires 2.5 activities of Accomm. and vergence throughout Tx! Closely monitor for A/S problems Takes longer to remediate than other vergence Dx

9. Pseudo CE Secondary to Accommodative Insufficiency Spread out, away from the horizontal axis –Bottom right: Pseudo CE 2º AI Usually requires an initial add –may be enough to remediate problem 3 accommodative activities /2 vergence activities

10. Pseudo CE Secondary to Accommodative Excess Spread out, away from the horizontal axis –Top right: Pseudo CE 2º AE Accommodative excess is usually the most dramatic feature here –Rarely above 2-3 prism diopters esophoria at near –Accommodative facility (relaxation) significantly affected 3 accommodative activities/2 vergence expected

11. General Approach for Vergence Dysfunction: “Rock” a patient from something they can accomplish with ease to something difficult This mantra of BV is still applied at the end of therapy (i.e. begin integrated convergence work with minus and BI).

12. General Approach for Vergence Dysfunction: Vergence Starting Point Vergence activities usually begun at the transitional level At times, very basic “walk-towards/away” therapy is necessary for several sessions

13. General Approach for Vergence Dysfunction: Accommodative Technique Starting Point A vergence patient with normal skills: –Will have difficulty controlling and adjusting vergence output with binocular level techniques –Would not be able to maintain vergence at a steady state on binocular accommmodative rock –In many cases, only 2-3 sessions at the trasitional level for vergence skills is required.

14. General Approach for Vergence Dysfunction: Anti- Suppression Starting Point Necessary if your therapy grinds to a halt because of suppression May occur at either the transitional or binocular level, for any modality.

15. General Approach for Vergence Dysfunction: Anti- Suppression Starting Point Blinking, flashing a penlight at the suppressing eye or tapping the target being suppressed may be all that is required When suppression is still preventing progress, the following activities would be called for:

16. Anti-Suppression Activities Transitional: –Vis-a-vis –Red/red rock without dioptric lenses –Doell’s Mazes or Litetrac series –Brock BU series/Morgenstern Basic Fusion cards Binocular: –Cheiroscopic tracings –AN and EC series

17. General Approach for Vergence Dysfunction: Oculomotor Starting Point Oculomotility skills may be affected in children with vergence dysfunction. A relatively high correlation exists between true convergence insufficiency and oculomotor dysfunction. When necessary, one (out of 5) activity in the orthoptics session will be OM

18. Cases: True CI (case #............) Vergence dysfunction Bad combination of –Low AC/A ration –Insufficient compensating vergence ranges (BO) DDx from Psuedo CI includes: –Difficulty w/+ on binocular accomm. Facility –No trouble w/ monocular –No plus acceptance/low lag/lead of accommodation

19. Cases: Pseudo CI (case #..........) Accommodation dysfunction w/ vergence “side-effects” Bad combination of –Poor accommodative control –debilitated vergence ranges (BO) “gives up the nearpoint ship”

20. Cases: Pseudo CI (case #..........) Cont. DDx from true CI includes: MINUS –Difficulty clearing MINUS on monocular and binocular +/-2.00 facility –May have difficulty with plus binoc. facility (if PRC is low enough) –Plus acceptance/high lag –some improvement with plus