Abstract: Purpose: Early studies reported some abnormalities in saccade and vergence eye movements in children with vertigo and vergence deficiencies. The purpose of this study was to further examine saccade and vergence performance in a population of 44 children (mean age: 12.361.6 years) with vertigo symptoms and with different levels of vergence abnormalities, as assessed by static orthoptic examination (near point of convergence, prism bar and cover-uncover test). Methods: Three groups were identified on the basis of the orthoptic tests: group 1 (n = 13) with vergence spasms and mildly perturbed orthoptic scores, group 2 (n = 14) with moderately perturbed orthoptic scores, and group 3 (n = 17) with severely perturbed orthoptic scores. Data were compared to those recorded from 28 healthy children of similar ages. Latency, accuracy and peak velocity of saccades and vergence movements were measured in two different conditions: gap (fixation offset 200 ms prior to target onset) and simultaneous paradigms. Binocular horizontal movements were recorded by a photoelectric device. Results: Group 2 of children with vergence abnormalities showed significantly longer latency than normal children in several types of eye movements recorded. For all three groups of children with vergence abnormalities, the gain was poor, particularly for vergence movement. The peak velocity values did not differ between the different groups of children examined. Interpretation: Eye movement measures together with static orthoptic evaluation allowed us to better identify children with vergence abnormalities based on their slow initiation of eye movements. Overall, these findings support the hypothesis of a central deficit in the programming and triggering of saccades and vergence in these children.

Abstract: Aims: To determine the current assessment and management strategies of orthoptists for patients with visual problems after stroke and to identify barriers to effective orthoptic management and priorities for future research. Methods: A questionnaire was designed to gather information about vision assessments, protocols and treatments during the management of patients with stroke. Information was also collected on barriers experienced and priorities for future research. One orthoptist from each hospital eye department in Scotland was identified, telephoned and sent a questionnaire. Results: We identified 14 orthoptists, covering the whole geographical area of Scotland. The questionnaire response rate was 100%. We collected detailed information on assessments and treatments used in the orthoptic management of patients with stroke. Twelve (86%) orthoptists reported that their unit did not have a protocol or management plan specific to stroke patients. The most commonly reported treatment strategies for patients with eye movement problems were provision of prisms, advice on head posture and convergence exercises. Provision of an explanation or advice was the most common management strategy for patients with visual field problems or visual neglect. The main barriers identified were a lack of a management plan (57%) and lack of funding (36%). Conclusions: We have determined key aspects of the orthoptic management of patients with visual problems after stroke in Scotland. The results of this survey support the need for management plans and protocols specific to patients with stroke, and confirm a number of priorities for future research into the orthoptic management of visual problems after stroke.

Abstract: Purpose To report orthoptic changes after photorefractive keratectomy (PRK). Methods This interventional case series included 297 eyes of 150 patients scheduled for PRK. Complete ophthalmologic evaluations focusing on orthoptic examinations were performed before and 3 months after PRK. Results Before PRK, 2 (1.3%) patients had esotropia which remained unchanged; 3 (2%) patients had far exotropia which improved after the procedure. Of 12 cases (8%) with initial exotropia at near, 3 (2%) cases became orthophoric, however 6 patients (4%) developed new near exotropia. A significant reduction in convergence and divergence amplitudes (P < 0.001) and a significant increase in near point of convergence (NPC) (P < 0.006) were noticed after PRK. A reduction ≥ 10 PD in convergence amplitude and ≥ 5 PD in divergence amplitude occurred in 10 and 5 patients, respectively. Four patients had initial NPC > 10 cm which remained unchanged after surgery. Out of 9 (6%) patients with baseline stereopsis > 60 seconds of arc, 2 (1.33%) showed an improvement in stereopsis following PRK. No patient developed diplopia postoperatively. Conclusion Preexisting strabismus may improve or remain unchanged after PRK, and new deviations can develop following the procedure. A decrease in fusional amplitudes, an increase in NPC, and an improvement in stereopsis may also occur after PRK. Preoperative evaluation of orthoptic status for detection of baseline abnormalities and identification of susceptible patients seem advisable.

Abstract: Purpose: To report orthoptic changes after photorefractive keratectomy (PRK). Methods: This interventional case series included 297 eyes of 150 patients scheduled for PRK. Complete ophthalmologic evaluations focusing on orthoptic examinations were performed before and 3 months after PRK. Results: Before PRK, 2 (1.3%) patients had esotropia which remained unchanged; 3 (2%) patients had far exotropia which improved after the procedure. Of 12 cases (8%) with initial exotropia at near, 3 (2%) cases became orthophoric, however 6 patients (4%) developed new near exotropia. A significant reduction in convergence and divergence amplitudes (P 10 cm which remained unchanged after surgery. Out of 9 (6%) patients with baseline stereopsis > 60 seconds of arc, 2 (1.33%) showed an improvement in stereopsis following PRK. No patient developed diplopia postoperatively. Conclusion: Preexisting strabismus may improve or remain unchanged after PRK, and new deviations can develop following the procedure. A decrease in fusional amplitudes, an increase in NPC, and an improvement in stereopsis may also occur after PRK. Preoperative evaluation of orthoptic status for detection of baseline abnormalities and identification of susceptible patients seem advisable.

Abstract: Background: Accommodative insufficiency (AI) is a relatively common visual anomaly in children and young adults with an estimated prevalence of about 5%. Patients with AI usually suffer from blur, headaches and asthenopia associated with near work. The two most important treatment regimes for AI are plus lens reading additions (PLRA) and orthoptic exercises with the aim of normalising the accommodative system. The stimulus for the accommodative system is blur, which is an even-error signal, i.e., the blur gives the magnitude of the accommodation, but lacks the directional information; therefore, it is dependent on other cues to know if the accommodation needs to be increased or reduced. The main directional cues for the accommodative system are thought to be chromatic aberration (CA) and spherical aberration (SA). Recently there has been a large interest in the use of contact lenses to correct aberrations in order to create an improved image quality or create a near addition. Aims: The purpose was to evaluate the outcome of AI treatment, to investigate the effect on accommodation response when manipulating the directional cues to accommodation and to study the effect on accommodation when using a multifocal contact lens. Material and Methods: 46 children between 7-18 years of age, diagnosed with AI were dissipating in study I and II where they were treated with PLRA (+1.00 or +2.00D) or orthoptic exercise. In study III and IV, a normal group of 40 subjects were included (age 21 to 35) and 5 AI patients (age 10 to 18). They had their aberration and accommodation measured with and without accommodative cues present, and also with a multifocal contact lens which gives a near reading addition. Results: The result showed that there was no significant difference between the two treatment methods for AI patients. Further, there was a significant difference between the PLRA given, which indicates that the PLRA should not be of the higher strength. The accommodative response was not affected when the accommodative cues was eliminated or decreased. The multifocal contact lens was not able to relax the accommodation in young normal subjects and neither on AI subjects. Discussion: Results of our study and others have shown that vision therapy (PLRA and/or orthoptic exercises) can improve the time characteristic and magnitude of accommodation response with a persistent result. The PLRA of +1.00D is preferred to allow comfortable vision at near and at the same time exercise and stimulated the accommodative system rather than completely relieved. The SA and CA were showed to not be a strong directional cue for the accommodation which indicates that there are other cues more important for directional information. Since the multifocal contact lens was not able to relax the accommodation for neither of the subjects it is therefore unlikely that subjects with AI can be effectively treated with such lens. Conclusion: Based of the finding in the studies I would like to recommend that AI subjects can be treated with either +1.00D reading addition or orthoptic exercise, however, multifocal contact lenses should not be used for the treatment purpose of AI subjects.

Abstract: Patients admitted to hospital following a stroke, as part of the recovery process may require active intervention to relieve visual symptoms. The interventions include therapy, correct use of or modification to spectacles (including use of prisms), appropriate occlusion or the adoption of compensatory strategies to support ocular comfort. This paper falls into two sections. It initially provides an overview of the strategies currently used for vision problems found in patients who have had a stroke. It refers to the general indictors for intervention and the possible strategies that can be used. The second part of the paper looks at outcomes citing patient responses from a 2008 report to the Statewide Ophthalmology Service of the Greater Metropolitan Clinical Taskforce. The strategies reported include therapy, correct optical use, occlusion and diplopia relief and strategies to maximise ocular comfort. Approaches used are often simple and very effective in terms of patient comfort or educating other team members about the need to support a compensatory strategy. Some strategies require active follow-up with variable outcomes. The outcomes support the benefits of orthoptic intervention in the care of patients recovering from stroke.

Abstract: Aim: To discuss a presumed case of functional bilateral amblyopia which had an eventual diagnosis of Stargardt’s disease. Methods: Details are reported of a girl who presented to the Orthoptic Department at age 9 years having previously attended the orthoptic department as a young child. Documentation of the case is presented including the findings in childhood, the findings at later presentation and the findings when an eventual diagnosis was made. Results: The orthoptic findings for this girl when discharged at age 8 years differed considerably from the findings at age 9. When discharged at age 8 years she showed acuities of 6/6 right and 6/12 left. A minimal residual left esotropia was present. At representation 7 months later visual acuities had dropped to 6/24 right and left. No cause for the reduction in acuity could be found. Conclusions: Stargardt’s disease is an inherited condition which affects the macula. There is usually considerable sight loss although complete loss of vision is rare. Early in the disease the macula and the electroretinogram can appear normal, which slows the initial diagnosis. Subsequently children may be suspected of malingering. In time the characteristic changes in the retina facilitate a diagnosis.

Abstract: Aim: To present a small case series of patients with visual complications following primary acute cerebellar stroke, document the types of visual deficit that occur, examine recovery patterns and identify rehabilitation strategies available. Methods: A small, consecutive case series of patients referred to the Orthoptic Stroke Service at Sheffield Teaching Hospitals NHS Foundation Trust with primary acute cerebellar stroke in 2007–2008 is presented. The types of visual deficit that occurred and the orthoptist’s contribution to patient rehabilitation are outlined. Results: Seven patients were included in this series. All had manifest nystagmus with or without oscillopsia. The main complaint was of ‘blurred vision’. Nystagmus varied in different positions of gaze, down gaze being the most troublesome for rehabilitation. Other deficits identified were skew deviation, internuclear ophthalmoplegia, and fixation abnormalities including saccadic intrusions and square wave jerks. Recovery was often incomplete, although in most cases some functional improvement did occur and most often in primary position. Conclusions: Patients who have suffered cerebellar stroke, especially those with vague visual symptoms and those failing to respond to rehabilitation, should be referred for orthoptic assessment. This provides invaluable information that can explain difficulties with rehabilitation and give patients insight into their symptoms. Advice and therapy can help overcome problems in many cases.

Abstract: Aim: To report an interesting case of amblyopia in a child with a previous history of constant left strabismus and amblyopia treated with occlusion, who subsequently sustained an injury to the nonamblyopic eye. Methods: The case is presented of a 12-year-old child who injured his fixing right eye after falling from a chair onto the corner of a computer table. Ophthalmic and orthoptic findings are documented. Results: The child presented to the accident and emergency department, after transfer from another Trust, with an acute history of right eye penetrating injury. Examination revealed a superior corneal laceration which required surgical repair. Seven months after a successful corneal repair the patient was noted to be turning his head to the right when reading. Orthoptic examination revealed a change in fixation and an increase in visual acuity in the previously amblyopic eye from 6/12 to 6/6 þ 2 Snellen. Conclusions: The period of improvement of vision from amblyopia can extend beyond what was previously thought to be the limit for positive change. Despite previous treatment of amblyopia a spontaneous increase in visual acuity occurred and was maintained even when acuity was restored in the nonamblyopic eye.