NSBVA

Man Mohan Shah

M.Optom 2nd yr
 Content

• Common BV assessment
• NSBVA: Features, management
• Tests sensitivity and specificity
• Case example
 Abbreviations

• BV: Binocular vision

• NPC: Near point of convergence
• NPA: Near point of accommodation
• PFV: Positive fusional vergence
• NFV: Negative fusional vergence
• AF: Accommodative facility (M: monocular, B:
Binocular)
• VF: Vergence facility
• NRA/PRA: Negative/Positive relative accommodation
 BV assessment

• History
• Refraction
• BV tests
– Sensory
– Motor
– Vergence
– Accommodation
 BV assessment

•
• History •
Chief complaints
Occupational details
• Refraction • Ocular history
• Medical history
• BV tests • Family history
• Personal history
– Sensory
– Motor
– Vergence
– Accommodation
 BV assessment

• History
• Refraction
• PGP details
• BV tests • Objective/subjective refraction
•
– Sensory •
Binocular balancing
Finalizing power
– Motor
– Vergence
– Accommodation
 BV assessment

• History
• Refraction
• Stereo tests:
• BV tests • Fusion tests
– Sensory
– Motor
– Vergence
– Accommodation
 BV assessment

• History
• Refraction
• Ocular motility
• BV tests • Cover test
– Sensory
– Motor
– Vergence
– Accommodation
 BV assessment

• History
• Refraction
• NPC
• BV tests • Fusional vergence amplitude
• Vergence facility
– Sensory
– Motor
– Vergence
– Accommodation
 BV assessment

• History
• Refraction
• NPA
• BV tests • Accommodative facility
•
– Sensory •
Accommodative response
NRA/PRA
– Motor
– Vergence
– Accommodation
Normal Parameters (AAO)
Indian population Normative data
Tests importance
Minimum battery of tests
Correlation
 Symptoms

• Headaches
• Eye strain
• Blurred vision for distance/near
• Diplopia
 NSBV Anomalies

• Vergence anomalies • Accommodation

– Convergence (near) anomalies
• Insufficiency – Insufficiency
• Excess – Excess/spasm
• Basic – Infacility
– Divergence (distance)
• Insufficiency
• Excess
• Basic
– Vergence dysfunction
 Case-1
• 31/M, Headache and blurring of vision for near (more in the
evening), computer user daily 10 hrs
Parameters Values
Refraction OU: +0.75D (6/6,N6 @ 30cm)
Dry Retino: +2.25 (OU)
Cover test Ortho (D&N)
NPC A/T: 7/8
R/G: 14/16
Obj: 7/8

NPA(cm) OD:22, OS:21.5, OU:20

NRA/PRA +3.25/-2.00
Accommodative response +0.75D /+0.75D
Fusional vergence Dist. NFV: x/8/6
PFV: x/16/14

Fusional vergence Near NFV: x/14/12

PFV: x/35/30

Accommodative facility 0/0/0 (Fails Minus)

Vergence facility 13 (equally fuses both)
• Accommodation anomalies
– Insufficiency
Signs:
– Excess • Reduced accommodation amplitude
• May show high lag on MEM
– Infacility
Treatment:
• Additional plus
• Vision therapy
• Accommodation anomalies
– Insufficiency
– Excess Signs:
• Reduced MAF and BAF (difficulty with
– Infacility both + & -)
• May show decreased NRA/PRA

Treatment:
• Additional plus (? Low NRA)
• Vision therapy
• Accommodation anomalies
– Insufficiency
Signs:
– Excess/Spasm • Fluctuating refraction (? Minus /plus)
• Neutral or lead of accommodation on
– Infacility MEM
• Reduced NRA
• Difficulty in clearing plus in MAF

Treatment:
• Cycloplegic refraction
• Near add (?Low NRA)

What to look for:

• Varying retino-reflex (Dist. and Near)
• Eso for near
 Case-2
• 19/M student, headache, blurring of vision and squinting
(75%) since 3 years, no double vision
Parameters Values
Refraction OD: -1.00/-0.75*10 (6/6,N6)
OS: -1.75/-0.50*180 (6/6, N6)
Cover test IDS-AXT, Dist: 10BI, Near: 30BI
NPC A/T: 7/10
R/G: 10/12
Obj: 7/10
NPA OD:7, OS:7, OU:8
NRA/PRA +2.75/-3.75
Accommodative response +0.25D /+0.25D
Fusional vergence Dist. NFV: x/20/12
PFV: x/16/14
Fusional vergence Near NFV: x/20/18
PFV: x/30/25
Accommodative facility 7.5/2/5 (Difficulty plus)
Vergence facility 11 (Difficulty in BO)
 NSBV Anomalies

• Vergence anomalies
– Convergence (near) Signs:
• Exophoria D & N, Low AC/A ratio
• Insufficiency • Receded NPC
• Excess • Reduced PFV

• Basic Treatment:
• Vision therapy (IVT & HVT)
– Divergence (distance) • BI prism
• Insufficiency
• Excess
• Basic
– Vergence dysfunction
 Case-3
• 31/M, C/O outward squinting (25%) of eyes after prolonged
near work since 25 years
Parameters Values
Refraction OD: -2.00/-3.00*80 (6/6,N6)
OS: -3.00/-2.50*80 (6/6, N6)
Cover test IDS-LXT-AXT, Dist: 40BI, Near: 25BI
Stereo: 100sec of arc
NPC A/T: 5/7
R/G: 8/10
Obj: 5/7
NPA OD:6, OS:6, OU:6
NRA/PRA +2.75/-5.00
Accommodative response +0.50D /+0.75D
Fusional vergence Dist. NFV: x/Supp
PFV: x/Supp
Fusional vergence Near NFV: x/25/18
PFV: x/Supp
Accommodative facility 7/6/7.5 (Difficulty clearing both)
Vergence facility 13 (Difficulty in both)
 NSBV Anomalies

• Vergence anomalies
– Convergence (near)
• Insufficiency Signs:
• Excess • Exophoria D & N (IXT),
• High AC/A ratio (?gradient normal)
• Basic • May be normal PFV & NFV
– Divergence (distance) Treatment:
• Insufficiency • Additional minus power (high AC/A)
• Vision therapy (IVT & HVT)
• Excess • Occlusion therapy
• Basic • Surgery

– Vergence dysfunction
 Case-4
• 26/F , IT by profession, blurring of vision for near without
glasses
Parameters Values
Refraction OU: (6/6,N6)
Cover test Dist: Ortho, Near: esophoria 6BO
NPC A/T: ttn
R/G: 16/20
Obj: ttn
NPA OD:12, OS:13, OU:12.5
NRA/PRA +1.75/-0.75
Accommodative response +0.75D /+0.75D
Fusional vergence Dist. NFV: x/8/6
PFV: x/8/6
Fusional vergence Near NFV: x/30/25
PFV: x/>40
Accommodative facility 2/3.5/4.5 (Difficulty Plus)
Vergence facility 8 (Fails BI)
 NSBV Anomalies

• Vergence anomalies
– Convergence (near) Signs:
• Esophoria D & N
• Insufficiency • High AC/A ratio
• Excess • Receded NPC
• Low NFV
• Basic • May show high lag on MEM
– Divergence (distance) Treatment:
• Insufficiency • Additional plus power
• BO prism
• Excess • Vision therapy (IVT & HVT)
• Basic
– Vergence dysfunction
 Case-5
• 32/M, IT by profession, Blurring of vision with headache since
3 years after prolonged near work
Parameters Values
Refraction OD: +0.50/-0.50*180 (6/6,N6)
OS: +0.00/-0.50*180 (6/6, N6)
Cover test Esophoria Dist: 10BO, Near: 2BO
NPC A/T: ttn
R/G: 10/14
Obj: ttn
NPA OD:19, OS:19, OU:18
NRA/PRA +2.75/-3.75
Accommodative response +0.50D /+0.50D
Fusional vergence Dist. NFV: x/6/4
PFV: x/20/18
Fusional vergence Near NFV: x/10/8
PFV: x/25/20
Accommodative facility 8/7.5/5.5 (Difficulty with both)
Vergence facility 11 (Difficulty in BI)
 NSBV Anomalies

• Vergence anomalies
– Convergence (near)
• Insufficiency
• Excess Signs:
• Esophoria D & N
• Basic • Low AC/A ratio
– Divergence (distance) • Reduced NFV findings

• Insufficiency Treatment:
• BO prism
• Excess • Vision therapy (IVT & HVT)
• Basic • surgery

– Vergence dysfunction
 Case-6
• 16/M student, intermittent headache and watering of eyes
since 2 months while doing near work
Parameters Values
Refraction OU: (6/6,N6)
Cover test Exophoria Dist: 4BI, Near: 10BI
NPC A/T: 13/15
R/G: 17/20
Obj: 12/14
NPA OD:7, OS:6, OU:7
NRA/PRA +2.25/-2.50
Accommodative response +0.75D /+0.25D
Fusional vergence Dist. NFV: x/10/8
PFV: x/16/14
Fusional vergence Near NFV: x/14/12
PFV: x/16/14
Accommodative facility 1/0/3 (Difficulty Plus)
Vergence facility 2 (Difficulty BO)
 NSBV Anomalies

• Vergence anomalies
– Convergence (near)
• Insufficiency
• Excess
• Basic Eso
– Divergence (distance) Signs:
• Normal phoria at D & N
• Insufficiency • Low NFV & PFV for D and N
• Excess • Reduced PRA & NRA
• Reduced BAF, normal MAF
• Basic Exo
Treatment:
– Vergence dysfunction • Vision therapy (IVT & HVT)
 NSBV Anomalies

• Vergence anomalies
– Convergence (near)
Signs:
• Insufficiency • Similar Esophoria D and N
• Excess • Low NFV for D and N
• May show high lag on MEM
• Basic Eso
– Divergence (distance) Treatment:
• Additional plus power
• Insufficiency • BO prism
• Vision therapy (IVT & HVT)
• Excess
• Basic Exo
– Vergence dysfunction
 NSBV Anomalies

• Vergence anomalies
– Convergence (near)
• Insufficiency
Signs:
• Excess • Similar Exophoria D and N
• Basic Eso • Receded NPC
• Low PFV for D and N
– Divergence (distance)
Treatment:
• Insufficiency • Vision therapy (IVT & HVT)
• Excess • BI prism
• Surgery
• Basic Exo
– Vergence dysfunction
Thank you
 References

• Kristine B. Hopkins, Managing Accommodative and Vergence Dysfunction;

AAO Meeting, Boston 2011
• Hussaindeen, J. R., et al; (2018). The minimum test battery to screen for
binocular vision anomalies: report 3 of the BAND study. Clinical and
Experimental Optometry, 101(2), 281–287.
• Hussaindeen, J. R., et al., Prevalence of non-strabismic anomalies of
binocular vision in Tamil Nadu: report 2 of BAND study. Clinical and
Experimental Optometry, 100(6), 642–648.
• Hussaindeen, J. R., et al., (2016). Binocular vision anomalies and normative
data ( BAND ) in Tamil Nadu : report 1. Clinical and Experimental
Optometry, 100(3), 278–284
• Cacho-Martínez, P., García-Muñoz, A., & Ruiz-Cantero, M. T. (2013).
Diagnostic validity of clinical signs associated with a large exophoria at
near. Journal of ophthalmology, 2013, 549435.
 Case-7
• 20/M BDS student, intermittent headache since 3 months
while doing near task (reading, VDU)
Parameters Values
Refraction OU: (6/6,N6)
Cover test Ortho (flick eso-exo), Dist: 4BO, Near: 0
NPC A/T: 9/11
R/G: 15/17
Obj: 9/11
NPA OD:8, OS:8.5, OU:8
NRA/PRA +2.00/-3.00
Accommodative response +0.25D /+0.25D
Fusional vergence Dist. NFV: x/4/2
PFV: x/8/6
Fusional vergence Near NFV: x/16/14
PFV: x/14/12
Accommodative facility 3/4.5/7 (Difficulty Plus)
Vergence facility 0 (Fails BO)
 Case-8
• 18/F student (+2), Headache after prolonged near work since
11 months
Parameters Values
Refraction OD: -2.25D (6/6,N6)
OS: -2.25D (6/6, N6)
Cover test Dist: Ortho, Near: Exophoria (3BI)
NPC A/T: TTN
R/G: 10/13
Obj: TTN
NPA OD:5, OS:5, OU:6
NRA/PRA +3.25/-2.00
Accommodative response +0.50D /+0.50D
Fusional vergence Dist. NFV: x/10/8
PFV: x/25/20
Fusional vergence Near NFV: x/18/16
PFV: x/25/20
Accommodative facility 4.5/3/4 (Difficulty plus)
Vergence facility 13 (equally fuses both)