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MODULE 10:4 • COURSE CODE: C-5199

Binocular vision anomalies: Part 2

Heterotropia
Bruce Evans
38 When one eye is covered, it is quite normal for a person to have a deviation in
the eye that is covered: a heterophoria is a normal situation. In Part 1 of this
series it was noted that there are three main factors that determine whether a
6/04/07 CET

heterophoria is compensated: the size of the deviation, motor fusion

(quantified as the fusional reserves), and sensory fusion. A person may have
trouble compensating for a heterophoria because the deviation is so large, or
the motor fusion or sensory fusion are lacking. Occasionally, the
decompensation might be triggered by a change in visual demands or habits,
such as a sudden increase in the amount of very close work. In these cases,
advice about changes to the working environment may be all that is necessary
to alleviate the symptoms. The present article is about heterotropia, which
occurs when the person is unable to compensate for the deviation and develops
a strabismus. This article is written from the perspective of the community
optometrist. When the community optometrist has a patient with heterotropia
sitting their chair, what tests do they need to do and what management options
are available to them? The answers to these questions are dependent on the age
of the patient, and so this article will be divided into two sections for different
age-groups. Adults have not been included since this series of articles is about
paediatric optometry.

Heterotropia in Infantile esotropia syndrome patient is seen. When these types of

Constant strabismus with an age of strabismus are found in young
pre-school children onset before one year is most children, they should be referred fairly
commonly infantile esotropia rapidly for a surgeon's opinion. The
First, the main types of heterotropia in syndrome in which case it will require prognosis for sensory and motor fusion
pre-school children will be described. referral. This is also known as early is poor, but is significantly improved
Then the investigative procedures acquired esotropia and used to be by early surgical intervention, if
appropriate for these conditions will be called congenital strabismus, although possible at about three months of age.
discussed. it is not usually present at birth. There is no justification for waiting
Infantile esotropia may be caused by until the child is old enough for
an innate defect of fusion and is fairly sensory testing (Ansons & Spencer,
Neonatal misalignments easy to recognise since the following 2001).
Brief neonatal misalignments of the clinical characteristics are present: An early interruption to
visual axes commonly occur in the first onset in first 6 months, large (>30Δ) binocularity, typically from infantile
month of life and should become less stable angle, and initial alternation esotropia syndrome, often results in
frequent in the second month with crossed fixation. three clinical signs which persist
(Horwood, 2003). Even up to the age of These cases may be further throughout life, even if the visual axes
five months, intermittent esotropia subdivided as essential infantile are surgically straightened. These three
frequently resolves if the deviation is esotropia, nystagmus blocking conditions are latent nystagmus,
less than 40Δ and is intermittent or syndrome, or a sixth nerve palsy. None dissociated (vertical) deviation (DVD),
variable. These cases should be of these types of strabismus will and inferior oblique overaction. Latent
monitored closely for amblyopia, even respond to optometric treatment nystagmus is a horizontal nystagmus
if the deviation seems to be improving. regardless of the age at which the that is either only present or greatly

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increased on monocular occlusion and difficult, especially since an optometric management and will
always beats towards the uncovered intermittent esotropia or microtropia require prompt referral to investigate
eye. In DVD, each eye deviates also might be present. Even if the the aetiology of the deviation.
upwards when it is covered, giving the optometrist is confident that there is
appearance of alternating hyperphoria. no esotropia present at the time of the Investigation
Often, the eye starts to deviate before appointment, the child still needs to When pre-school children present to
the occluder actually covers the eye. be monitored closely and a cycloplegic the optometrist with heterotropia, it is
refraction is advisable. likely to be of recent onset. In such
Infantile accommodative esotropia cases, there are three main goals for
As many as 15% of patients with Exotropia the clinical investigation of the 39
infantile esotropia may have infantile Intermittent exo-deviations (divergent strabismus. First, the practitioner must
accommodative esotropia, nearly half drifts) are quite common up to the age take reasonable steps to detect

6/04/07 CET
of whom can be fully straightened of six months and should only be pathology. In pre-school children,
with spectacles. The earlier correction considered abnormal if they become ‘reasonable steps’ usually means
begins, the better the chances of more constant or persist beyond six assessing pupil reactions and
success, and if more than +2.25D is months (Sondhi et al., 1990). Some ophthalmoscopy. Further investigation
detected in an infant with esotropia authors argue that early onset (eg electrophysiology or neuro-
then spectacles should be tried before exotropia is likely to be associated imaging) are not generally felt to be
surgery (Havertape et al., 1999). with nervous system pathology, appropriate unless these initial steps
Surgery is only indicated on the although others disagree. In any event, reveal an abnormality (eg, suspicious
portion of the deviation that spectacles constant exotropia in a pre-school discs) or the heterotropia is atypical
do not control after a trial of two-three child is unlikely to respond to (eg, increasing in angle, incomitant,
months, and spectacle wear should be
continued after surgery. General goal Detail Tests
Is retinal pathology Ophthalmoscopy, usually with pupil dilation, rarely in hospital
Esotropia after the first year of life present? under anaesthesia
Esotropia with an onset after the first • are there any other systemic signs of CNS pathology (eg,
year of life will not be infantile epileptic fits)
esotropia syndrome and the chances of Is central nervous system • test pupil reactions
there being a significant (CNS) pathology present? • examine optic discs
Detect pathology • check for incomitancy
accommodative element increase.
• look for nystagmus
Cycloplegic refraction and, if
significantly hypermetropic, full plus • Is the child dysmorphic?
prescription for constant wear are Is other systemic • Are there other health problems (e.g., not developing or
pathology present? growing normally)?
required as soon as possible. If the
• Is the child’s behaviour or development unusual for their age?
esotropia is eliminated by spectacle
wear, then usually any amblyopia also • Strabismus
resolves, although some cases might • High hypermetropia
Is there a relevant
• Nystagmus
require occlusion. Constant occlusion family history?
• Amblyopia
should be avoided in these cases • Eye surgery in young children
because this could jeopardise the
• Complications during mother’s pregnancy
establishment of binocularity. The • Premature and / or low birth weight
treatment of these fully Find the cause of • Complications during birth (e.g., forceps, hypoxia)
accommodative cases is within the the heterotropia Is there a relevant • Complications after birth (e.g., jaundiced)
(assuming that no personal history? • Complications in first year (e.g., operations, severe illnesses)
scope of practice of the community
pathological • Illness (e.g., causing fever) around the time of onset of
optometrist. cause is apparent) heterotropia
Cases that cannot be straightened • Trauma (including non-accidental injury)
fully with spectacles will require
Is there an incomitant • Duane’s syndrome
referral for two reasons. First, they deviation that may have • Fourth nerve palsy
will require referral to investigate the been present since birth? • Sixth nerve palsy
aetiology of the strabismus, and
Is there a significant
second to investigate whether surgery refractive error?
• Cycloplegic refraction
would be helpful.
Quite often, the optometrist is Is it comitant? • Motility testing (see below)
presented with cases of suspected Determine the • Cover testing at
Type of deviation
pseudo-esotropia: where a large characteristics of distance & near
epicanthus leads the parent to suspect the heterotropia Is it accommodative? • Effect of refractive correction
a strabismus but where none can be Is amblyopia present? • Visual acuity testing
found on cover testing. Differential
diagnosis of epicanthus can be quite < Table 1 Summary of the investigation of heterotropia in pre-school children. See text.
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associated with nystagmus, amblyopia eyecare than, for example, routine

not responding to treatment). This dental care. Many of the children who
means that every case of heterotropia need eyecare most (eg, those from
should be investigated by either an deprived backgrounds, with learning
optometrist or an ophthalmologist; disabilities, or with specific learning
since these are the eye care difficulties) still do not receive
professionals who are skilled at professional eyecare. It is also a cause
ophthalmoscopy. for concern that many parents assume
To obtain a good view of the fundus that their children will have vision
40 in heterotropic pre-school children, routinely screened in schools. It is
pupil dilation is usually required. In < Figure 1 important for the profession to educate
some very young or very unco- the public that the school vision
6/04/07 CET

A Lea symbol presented in a 'crowded box' using

operative cases, a good view of the the computerised Test Chart 2000. Reproduced screening service has deteriorated in
fundus can only be obtained during with permission from Thomson Software Solutions. recent years, and in many places
general anaesthesia. Although the risk vision is only screened once, on
of serious pathology, such as crowded optotype tests and, as soon as school entry. This means that any
retinoblastoma, is only slight, the possible, this type of test should be refractive error or binocular vision
serious nature of this and other used. The computerised Test Chart anomaly that is either not detected at
conditions means that 2000 is extremely useful for this school entry, or develops after school
ophthalmoscopy under anaesthesia because a variety of optotypes can be entry, may be missed. Many parents
may be appropriate in suspicious presented, including lower case and nearly all grandparents will be
cases. letters, numbers, Lea symbols, and under the care of an optometrist and
The second goal of the clinical Kay pictures. These can be presented this is an opportunity for the
investigation is to find the cause of the in isolation, which makes the task profession to educate these people
strabismus. For the primary care easier for children, yet with crowding about the need for routine professional
optometrist the only aetiology that (Figure 1) which makes the test better eyecare in their children and
they may be able to manage in this age at detecting strabismic amblyopia. The grandchildren.
group is a purely refractive esotropia, optotypes can also be randomised, For younger children, who are in
so a cycloplegic refraction is which prevents that favourite trick of the first few years at school, the
important. An investigation of the young amblyopes memorising the management of strabismus is similar
personal and family history is also letter chart! to that outlined for pre-school
relevant (Table 1, page 39). If amblyopia is detected then it is children. However, the testing
The third goal is to determine the widely believed that treatment should becomes much easier as the children
characteristics of the strabismus. This be started as soon as possible. Even if understand optotypes and
is important for future monitoring and the optometrist is going to refer the communicate better, and the
to determine the priority for the child to a hospital eye clinic, it is still possibilities for optometric
referral. If there is a sudden onset often helpful for the optometrist to management improve since children
incomitant deviation then referral start amblyopia treatment if there is become more likely to cooperate with
should be urgent. likely to be a wait of a few months spectacle wear or eye exercises. In
Table 1 summarises the until the child is seen at the hospital. older teenagers, the management of
investigation of strabismus using the The treatment of strabismic amblyopia heterotropia is more akin to that for
three goals outlined above. It is easy to is described in more detail later in this adults. This section of the article
see why some community article. concentrates on the age range from 5-
optometrists do not feel happy 12 years, and there are two reasons for
managing these cases in the primary Heterotropia in this emphasis. First, it is quite
care setting. The only cases for which common for strabismus to develop
optometric management is appropriate
school children during this interval, because children
are the fully accommodative cases, Overview are starting to carry out a lot more
and the practitioner will need to be Optometrists are the main providers of detailed visual tasks and for longer
comfortable and experienced at testing eyecare to school children. Indeed, the periods. Second, amblyopia treatment
pre-school children and have the most common visual disorder in the becomes less successful and more
appropriate tests. In the first year of age-group is refractive error, and the risky after the age of about 7-8 years,
life, acuity assessment usually prescribing of refractive corrections is and is not usually treated beyond the
requires preferential looking grating almost exclusively the province of the age of 12 years.
cards. Over the age of one year, many optometrist in the UK. It is therefore
children can be tested with Cardiff not surprising that optometrists play a
acuity cards, which are more widely key role in the detection of Investigation
available. But these methods of heterotropia in this age-group. Aetiology
assessing acuity are not as good at Unfortunately, it is still much less One way of thinking about the
detecting strabismic amblyopia as common for children to have routine investigation of heterotropia, which
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was introduced in Table 1, is to look diagnose, but typically have

for a negative sign and a positive sign. 1. The amplitude of movement should always be amblyopia and eccentric fixation, as
The negative sign is the absence of estimated (in Δ) and recorded during cover described below.
testing.
pathology, and the tests for this in
2. It is easy to train yourself to be quite accurate at
Table 1 should be easier to carry out in this, and to regularly ‘calibrate’ your estimations. Strabismic amblyopia and binocular
schoolchildren than in pre-school On a typical Snellen chart, the distance from a sensory adaptations
children. Indeed, for most letter on one end of the 6/12 line to a letter on If a child in the first few years of life
schoolchildren visual field testing can the other end is about 12cm (measure this on develops a constant unilateral
be added to the tests listed in the first your chart to check). If the distance is 12cm, this strabismus then they will probably
means that when the patient changes their
section of Table 1. The positive sign is fixation between these two letters the eyes make develop strabismic amblyopia. This is 41
the detection of a cause for the a saccade of 2Δ (1Δ is equivalent to 1 cm at 1 characterised by reduced visual acuity
strabismus, and if a non-pathological in the strabismic eye which does not

6/04/07 CET
m).
cause is found (eg high 3. If you place two markings on the wall near the immediately improve with refractive
hypermetropia) then this greatly letter chart that are 24cm apart, when the patient correction. It is almost invariably
reduces the likelihood of a changes their fixation between these two marks associated with eccentric fixation. The
then the eyes are moving by 4Δ.
pathological cause being present. easiest way to detect this in
4. After you have done the cover test and estimated
The detection of positive signs the amplitude (in Δ) of the strabismic or
community practice is to use the
(non-pathological causes) in heterophoric movement, remove the cover and fixation star in the direct
strabismus have already been have the patient look between these two marks, ophthalmoscope. It helps to carry this
discussed for younger children (Table or between the two letters on the 6/12 line whilst test out on the non-amblyopic eye first
1) and is only slightly different in you watch their eyes. Compare the amplitude of to train the patient.
this eye movement with the amplitude of
older children. In esotropia, the movement that you saw during cover testing, to If an adult develops heterotropia
optometrist should look for check the accuracy of your estimate. then they are likely to have diplopia
hypermetropia, including a 5. A similar method can be used for larger and confusion.
cycloplegic refraction. Before the amplitudes. In young children (up to the teen
cycloplegic is instilled, the effect on 6. At near, this task is even easier. Use as your years), the onset of strabismus usually
the heterotropia of correcting the fixation target the numbers on a centimetre ruler leads to binocular sensory adaptations
refractive error revealed by ‘dry’ which you hold at ⅓ m. If the patient looks from to prevent diplopia. In small-angle
the 1 to the 2 then the patient’s eyes are moving
refraction should be investigated. If deviations, the patient usually
by 1cm which, at ⅓ m, equates to 3Δ.
the proposed refractive correction develops harmonious abnormal retinal
does not fully straighten the patient at correspondence (HARC) and in large-
Reproduced with permission from Evans, B.J.W. (2005) Eye
distance, then investigate the effect of Essentials: Binocular Vision. Elsevier, Oxford.
angle deviations there is usually
a reading addition at near. Usually, it suppression of the binocular field of
is enough to carry out the cover test < Table 2 the strabismic eye.
with the proposed refractive Estimating the angle in cover testing. From the perspective of the
correction. community optometrist, if a patient
also recognisable from the symptoms: has a strabismus and they do not have
Type of strabismus the patient may report episodes of diplopia then they must have a
Tests need to be carried out to diplopia and/or their family and binocular sensory adaptation. If the
determine the type of strabismus friends may report episodes when one strabismus has been there for some
which will in turn determine the eye deviates. time, then the sensory adaptation is
aetiology and indicate the prognosis Microtropia is usually defined as a likely to have developed during early
for optometric management. The key strabismus where the angle of childhood, whilst the visual system
tests are a cover test at distance and deviation is less than 10Δ. Most cases was most adaptable. In these cases, the
near, with and without any significant are unilateral esotropia and there are sensory adaptation is likely to be quite
change in refractive correction that has often deeply engrained sensory deeply ingrained and treatment to
been found. It is useful to record a adaptations that have caused some straighten the visual axes in these
quantification of the angle of deviation authors to describe this as a ‘fully cases is likely to be difficult and
(ie, ‘15Δ esotropia’ rather than adapted squint’. It is certainly true probably undesirable.
‘medium esotropia’) and to note the that most patients with microtropia This is because an attempt to treat
method that is used to obtain this are asymptomatic: they usually have or correct the angle without
(Evans, 2005). The two main methods no diplopia, coarse levels of eliminating the sensory adaptation
are estimation by observation (Table 2) stereoacuity on contoured tests (eg the could cause intractable diplopia. In
and measurement with the prism bar. Titmus circles), and do not appear to practice, the intervention that the
The cover test is good at detecting have any ocular deviation to the optometrist is most likely to prescribe
most types of strabismus, except for casual observer. Indeed, some cases do is a refractive correction. The effect of
some intermittent cases and for some not have any movement on cover this on the angle and on the sensory
types of microtropia. Intermittent testing: the angle of deviation is the adaptation can be predicted simply by
cases usually have a marked same as the angle of eccentric fixation. placing the proposed prescription in a
heterophoria on cover testing and are These cases can be very difficult to trial frame (Figure 2) and asking the
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The effect of a near add can be need referral for surgery. Similar
investigated, but obviously not whilst approaches can be tried in basic
the cycloplegic is still having an effect. exotropia.
As noted above, the proposed
prescription can be placed in a trial Hypertropia & cyclotropia
frame to ensure that it does not cause Hypertropia and cyclotropia are
diplopia. Often, patients whose usually the result of incomitant
esotropia is at near only can be deviations and new cases will require
effectively treated with multifocals, referral for an investigation of the
42 the aim being to gradually reduce the underlying cause. Occasionally, cases
add over time, as long as a reduction of long-standing (eg congenital)
does not cause the esotropia to return superior oblique palsy will be seen
6/04/07 CET

or an esophoria to decompensate. Any where the patient is just able to

amblyopia will need to be treated as compensate for the deviation at
outlined below. distance but may have an intermittent
or constant hypertropia of the affected
Exotropia eye for reading. In some cases, a
The most common form of exotropia vertical prism may allow comfortable
to occur under the age of 19 years is binocular single vision under a wider
intermittent exotropia. As noted range of viewing conditions. Before
earlier in this article, an unexplained prescribing, the prism should be tried
new deviation will require referral to a in a trial frame to see if it improves
neuro-ophthalmologist to investigate symptoms and, most importantly, to
< Figure 2 the aetiology. The cases that are check that it does not cause diplopia.
A case of fully accommodative esotropia amenable to optometric management
without (top) and with (bottom) refractive are those where there is a long- Strabismic amblyopia
correction. Reproduced with permission from standing exophoria that may be Amblyopia affects about 3% of the
Pickwell’s Binocular Vision Anomalies, 5th decompensating into an exotropia, population and the detection of
edition, B.J.W. Evans, Elsevier, Oxford, 2007. perhaps owing to an increase in near amblyopia is an important role for
visual tasks at school. primary eyecare practitioners. There
patient if they experience diplopia. If Exotropia can also be associated has been a great deal of research in
not, then the correction is likely to be with neurological abnormalities (eg recent years on this subject and there
safe to prescribe, but the patient cerebral palsy). Exotropia can be is only room here to briefly summarise
should be warned to return if any divided into three main categories: some of the key findings.
diplopia occurs. divergence excess (worse at distance), Where there is a strabismic
convergence weakness (worse at near), component to the amblyopia then
and basic exotropia (a significant treatment before the age of about 7-8
Management deviation at both distance and near). years is important for two reasons.
Esotropia Divergence excess characteristically Firstly, treatment before this age is
As noted earlier in this article, when presents as a deviation that occurs likely to be more successful than
esotropia is found then hypermetropia intermittently when the patient is treatment after this age. Secondly,
must be suspected and a cycloplegic looking in the far distance. It is treatment after this age is associated
refraction is indicated. It is not usually associated with suppression so with a small risk of causing intractable
uncommon to see primary school that the patient may be unaware that diplopia, and so should only be
children with moderate degrees of one eye has diverged markedly. It is undertaken cautiously by practitioners
hypermetropia who start to suffer more likely to occur with far distance who can carefully monitor the sensory
decompensation or intermittent fixation (eg looking out a window) status. These two reasons together
strabismus owing to increased than with the usual optometric 6m test explain why most practitioners do not
accommodative demand with distance. Eye exercises or negative recommend treatment of strabismic
schoolwork (Figure 2). If the esotropia lenses are sometimes helpful; more amblyopia after about the age of 8
has not become well-established then severe cases may need surgery. years.
correction with spectacles is usually Near vision exotropia (convergence There is a long history of patients
successful. weakness) may respond to optometric with strabismic amblyopia being
Esotropia that is eliminated when intervention and the prognosis for this treated in community optometric
hypermetropia is corrected is called is more favourable if the angle is less practices and this is just as
fully accommodative strabismus. If the than 20Δ and intermittent. The usual appropriate today as it has been in the
esotropia is not corrected with the full optometric interventions can be tried: past, as long as the practitioner has the
plus prescription, then it still might be eye exercises, refractive modification appropriate expertise and is used to
possible to straighten the visual axes (negative lenses), or prisms. Larger working with children. Of course, if
at least at near by using multifocals. angles, especially if permanent, may the heterotropia requires neuro-
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the child to sit near the front in class

when the occluder is worn.
1. Full correction of
Not every case of amblyopia
any significant
responds to treatment and some of
refractive error
those who do not respond may have
subtle degrees of optic nerve
18 weeks
hypoplasia. However, since the
diagnosis of amblyopia is one of
If still amblyopic 2. Part-time occlusion exclusion then the index of suspicion
of pathology being present must be 43
raised in those cases who do not
12 weeks respond to treatment. If there is any

6/04/07 CET
deterioration in acuity, or any other
3. Full-time occlusion risk factors, then referral is indicated.
If still amblyopic

Anisometropic amblyopia
12 weeks
Overview
4. When no more There are some important differences
improvement stop & between anisometropic amblyopia and
monitor strabismic amblyopia, particularly
concerning management. The main
difference is that strabismic amblyopia
< Figure 3
should be treated before the age of
Stages to the treatment of strabismic amblyopia. Recent research suggests that many
about 8 years, whilst anisometropic
cases improve with spectacles alone, or with part-time (2hrs a day) occlusion, and do
not need full-time occlusion. amblyopia can be treated at any age
(Evans, 2007b). Quite often,
ophthalmological investigation then clear instructions to the patient and anisometropia coexists with
referral is required, and guidance on should be aware that patient and heterotropia and, from the perspective
when this is appropriate was given parent concordance (compliance) is of treatment, these mixed cases need
earlier in this article. Even when often the key to success. This does not to be considered as strabismic
referral is required, then there is no just mean using a patch when advised, amblyopia. This means that it is
reason why the community but also making sure that the patch important to detect strabismus,
optometrist cannot start treatment of fully occludes and that spectacles fit particularly microtropia, in cases of
the amblyopia so that this can be properly. Contact lenses are a viable suspected anisometropic amblyopia.
underway whilst the patient is option in many cases (Evans, 2006).
awaiting a hospital appointment. The idea of patching is to cause an eye Investigation
There are four stages to the that has fallen into disuse to become In anisometropic amblyopia, it is
treatment of strabismic amblyopia used, at least when the patch is worn. necessary to correct the full degree of
(Figure 3), not all of which are It therefore helps to encourage the anisometropia. Therefore, in young
necessary in a given person. For child to carry out some detailed visual patients a cycloplegic refraction is
example, some cases will be cured of task when the patch is worn. This is required. It was noted earlier in this
amblyopia simply by refractive made much easier if the child likes the article that cases of microtropia will
correction, and will never progress task, such as a favourite DVD or usually be associated with eccentric
beyond stage 1 (Stewart et al., 2004). computer game. If the parents fixation. They are also likely to fail
Similarly, many cases do not require carefully control the viewing distance stereopsis tests, particularly those with
full-time occlusion. The timings in then the child can be encouraged to random dot targets. Some, but not all,
Figure 3 are debated: some experts monitor their high score on computer microtropic cases will show a
would suggest longer intervals and games as a way of helping them to heterotropic movement on cover
others shorter. It is wise to see patients appreciate the improvement in the testing. The four prism dioptre base
frequently during the treatment of amblyopia. out test is sometimes recommended as
amblyopia, to begin with every 4-6 It must be remembered that, if the the diagnostic test for microtropia, but
weeks. Penalisation is a viable option amblyopia is quite marked, a patient this test can give confusing results
to occlusion, for example using a may be rendered partially sighted (Frantz et al., 1992; Evans, 2007b).
cycloplegic (Repka et al., 2005) or a during the time when the good eye is
spectacle or contact lens that blurs the occluded. This may impact on Management
good eye at one or all distances. education, safety, and quality of life As already noted, there are some
Whoever treats amblyopia, whether and all these factors will need to be differences between the management
an optometrist, orthoptist, or carefully discussed with the parent. At of orthotropic anisometropic
ophthalmologist, will need to give the very least, it is helpful to ask for amblyopia and strabismic amblyopia.
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The first major difference is that, with they become less able to accommodate three times. A bright pen light is the
orthotropic anisometropic amblyopia, for the hypermetropia when they cover best fixation target and in the first test
stage 3 of the treatment for strabismic their good eye. These cases can be the corneal reflection of the pen light
amblyopia that was outlined in Figure offered a correction, ideally a contact is used to evaluate the eye movements
3 is inappropriate, since full-time lens, for their more hypermetropic eye. and detect any under- or over-actions.
occlusion could cause the binocular Care should be taken that the nose
vision to break down. A second does not occlude the pen light, when
difference is that, since non-strabismic Incomitancy its corneal reflection will disappear. In
anisometropic amblyopia is essentially Overview the second version of the motility test,
44 a refractive problem, it is very likely An incomitant deviation is one in an alternating cover test is used in
that it will respond to simple which the angle of deviation varies peripheral gaze to determine the
refractive correction. A seminal paper depending on the direction of gaze position of gaze where there is the
6/04/07 CET

in 1988 showed that for all types of and on which eye is fixating. A new or maximum deviation, and what type of
anisometropia contact lenses are better changing incomitancy can be a sign of deviation is present in this position. In
than spectacles at controlling pathology and requires referral. Long- the third version of the test the patient
aniseikonia (Winn et al., 1988). These standing cases require monitoring by is asked to report any diplopia. This
authors noted that in children with the community optometrist in case can be instructive in some cases, but
anisometropia, contact lenses therefore they decompensate. very confusing in others. Some
provide a more potent stimulus to the patients suppress and so do not report
binocular system. Silicone hydrogel Investigation diplopia and others provide confusing
contact lenses have made continuous The first indication that an incomitant descriptions of diplopia, sometimes
wear possible for these cases and this deviation may be developing usually because their convergence is breaking
can be a very good option, if the usual comes from the symptoms. Adult down for the pen light, which is a
criteria for safe contact lens wear are patients will probably report diplopia poor stimulus to fusion.
met (Evans, 2006). and for child patients, a parent will In uncertain cases, or when there is
The third major difference between usually notice a ‘turning eye’ and a pre-existing incomitancy that the
anisometropic and strabismic questioning may reveal that this is optometrist wishes to monitor, it can be
amblyopia is that the majority of more noticeable when they look in a very useful to obtain a plot of the
studies have indicated that in non- certain direction. The key test for incomitant deviation that can be
strabismic anisometropic amblyopia diagnosing an incomitant deviation is repeated after a few weeks or a few
the amblyopia can respond to the ocular motility test. This is a very months. Hess or Lees screens are
treatment at any age (Evans, 2007b). simple test to do with a comitant designed for this and any Windows PC
Quite commonly in optometric patient, but it is much harder to use can be used with the Thomson
practice one comes across adults who the test to reveal information about the Software Solutions Hess Screen. Other
have one moderately hypermetropic type and severity of an incomitancy. diagnostic approaches are described in
eye that has never received correction. Really, there are three motility tests more detail in other texts (Evans, 2002)
In young adulthood these patients can and when evaluating a patient with an The three most common
become alarmed from increasing blur as incomitancy it is useful to do the test incomitancies seen in optometric

< Figure 4
Successive computerised Hess plots of a resolving right lateral rectus palsy. Reproduced with permission from Evans (2002) Pickwell’s Binocular
Vision Anomalies, 4th edition, Elsevier, Oxford.
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practice are Duane’s syndrome, experiencing intermittent diplopia for References

superior oblique palsy, and lateral some years which is gradually Ansons, A. & Spencer, A. (2001). The
rectus palsy. Duane’s syndrome is a becoming more frequent and an medical management of strabismus. In
congenital mechanical incomitancy: incomitant deviation is found then a Binocular Vision and Orthoptics, eds.
there is a restriction of horizontal more routine referral is likely to be Evans, B. J. W. & Doshi, S., pp. 101-109.
movement in one or both eyes. The appropriate. Butterworth-Heinemann, Oxford.
affected eye(s) may fail to abduct, A sudden onset third nerve palsy Evans, B. J. W. (2002). Pickwell' s Binocular
adduct, or both: the eye looks as if it requires emergency referral, but Vision Anomalies, Fourth ed. Elsevier,
is tethered. Classically (but not thankfully is only seen rarely in Oxford.
always), there is a retraction of the eye optometric practice. Evans, B. J. W. (2005). Eye Essentials:
45
and associated lid closure on Indeed, the community optometrist Binocular Vision Elsevier, Oxford.
adduction. Patients usually adapt to is much more likely to see patients Evans, B. J. W. (2006). Orthoptic

6/04/07 CET
the condition well, experience no with long-standing incomitancies. indications for contact lens wear.
diplopia, and typically adopt a head If the patient is asymptomatic then Cont.Lens Anterior Eye 29, 175-181.
position that allows normal binocular it is best to try not to change the status Evans, B. J. W. (2007a). Monovision: a
vision. The condition can be quo. review. Ophthal.Physiol.Opt. in press.
associated with other congenital Some cases of fourth nerve palsy Evans, B. J. W. (2007b). Pickwell's
abnormalities, so it is sensible to refer manage to maintain binocular single Binocular Vision Anomalies, 5th ed.
the condition if an optometrist first vision in the primary position, but are Elsevier, Oxford.
detects it in a child. likely to have a hyperphoria in the Frantz, K. A., Cotter, S. A., & Wick, B.
The lateral rectus and the superior affected eye. If this is causing (1992). Re-evaluation of the four prism
oblique muscles are each innervated symptoms, then it can be helped by a diopter base-out test. Optometry and
by their own nerves: the sixth and small vertical prism, which can be Vision Science 69, 777-786.
fourth nerves respectively. These prescribed with the Mallett unit (see Havertape, S., Whitfill, C., & Oscar, C.
nerves have long pathways and are Part 1). Since these cases may have (1999). Early-onset accommodative
prone to damage, for example from particular difficulty when looking esotropia. J.Paed.Ophthal.& Strabismus 36,
high blood pressure, diabetes, stroke, down and in, multifocal spectacles or 69-73.
trauma, and other vascular and translating designs of multifocal Horwood, A. (2003). Neonatal ocular
neurological anomalies. If a patient contact lenses may be misalignments reflect vergence
presents with diplopia of recent onset contraindicated. This is because development but rarely become esotropia.
then a problem with one of these forcing the patient to look in the field British Journal of Ophthalmology 87, 1146-
nerves should be suspected. If the of action of the affected muscle could 1150.
lateral rectus is affected then the cause the incomitancy to Repka, M. X., Wallace, D. K., Beck, R. W.,
major component of the diplopia will decompensate (worsen). Indeed, any Kraker, R. T., Birch, E. E., Cotter, S. A.,
be horizontal and the diplopia (and incomitant deviation can Donahue, S., Everett, D. F., Hertle, R. W.,
the eso-deviation) will be worse with decompensate after a number of years Holmes, J. M., Quinn, G. E., Scheiman, M.
distance fixation and when the patient of stability, and so it is best not to do M., & Weakley, D. R. (2005). Two-year
looks to the side of the affected anything to interfere with their ocular follow-up of a 6-month randomized trial of
muscle. motor status. For example, atropine vs patching for treatment of
If the superior oblique is affected monovision is contraindicated for moderate amblyopia in children. Arch
then the diplopia will be long-standing cases of incomitancy, or Ophthalmol 123, 149-157.
predominantly vertical and is often indeed for unilateral comitant Sondhi, N., Archer, S. M., & Helveston, E.
worse on downgaze. There are strabismus (Evans, 2007a). M. (1990). Development of normal ocular
exceptions to this pattern, because Some cases of long-standing lateral alignment. Journal of Pediatric
secondary sequelae to the palsy may rectus palsy can be helped by a base Ophthalmology and Strabismus 25, 210-
occur over time. out prism for the affected eye in 211.
distance vision spectacles. These Stewart, C. E., Moseley, M. J., Fielder, A.
Management cases may benefit from vocational R., Stephens, D. A., & and the MOTAS
The most important point to stress advice: for example, it would be best cooperative (2004). Refractive adaptation
about incomitant deviations are that for an affected child to be positioned in amblyopia: quantification of effect and
they can be a sign of pathology and in the classroom so that they look implications for practice. British Journal of
new or changing incomitant away from the side of the affected Ophthalmology 88, 1552-1556.
deviations require referral. The speed muscle when they look at the board or Winn, B., Ackerley, R. G., Brown, C. A.,
of onset of symptoms is a good guide teacher. Murray, F. K., Prais, J., & St, J. M. F. (1988).
to the required speed of referral. If a Similarly, most children with a Reduced aniseikonia in axial
patient woke up today with constant congenital superior oblique palsy anisometropia with contact lens correction.
diplopia that they have never had would find it helpful when using a Ophthal.Physiol.Opt. 8, 341-344.
before and an incomitant deviation is computer at home to place the
apparent on testing then a very urgent monitor higher than usual.
referral is required. If they have been
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Module questions Course code: c-5199

Please note, there is only one correct answer. Enter online or by form provided
An answer return form is included in this issue. It should be completed and returned to CET initiatives (c-5199) OT,
Ten Alps plc, 9 Savoy Street, London WC2E 7HR by 2007.
1. Which one of the following is correct regarding neonatal misalignments? 8. Which one of the following statements is correct?
a. They are extremely rare a. It is wrong for fully accommodative esotropia to be treated in optometric
b. They invariably indicate infantile esotropia syndrome practice
c. They should become less frequent in the second month of life b. It is wrong for fully accommodative esotropia to be treated in the hospital
d. The child will grow out of them so they do not need monitoring eye service
c. It is wrong for fully accommodative esotropia to be treated surgically
46 2. Which one of the following is not a common feature of infantile esotropia d. It is wrong for fully accommodative esotropia to be treated with spectacles
syndrome?
a. Onset in the first six months of life 9. Which one of the following is the most accurate description of divergence
6/04/07 CET

b. Nystagmus with an onset in adulthood excess intermittent exotropia?

c. Large stable angle a. The deviation is greatest for far distance vision and the patient is typically
d. Initial alternation with crossed fixation unaware because they suppress when the eye deviates
b. The deviation is greatest at 3m and the patient is typically unaware because
3. Which one of the following is correct regarding epicanthus? they suppress when the eye deviates
a. If epicanthus is present, then an esotropia cannot be present c. The deviation is greatest for far distance vision and the patient usually
b. The presence of an epicanthus combined with parental reports of an experiences diplopia when the eye turns
esotropia is not an adequate reason to provide a GOS sight test d. The deviation is greatest for far distance vision and the patient is typically
c. Epicanthus can co-exist with intermittent esotropia unaware because they have HARC when the eye deviates
d. If no esotropia is found at an eye examination, then further follow-up is not
required 10. Which one of the following statements is correct?
a. Anisometropic amblyopia is not suitable for correction with contact lenses
4. Which one of the following is not a significant risk factor for strabismus in b. In young patients with anisometropic amblyopia, a cycloplegic refraction is
young children? unnecessary
a. Family history of primary open angle glaucoma c. Anisometropic amblyopia treatment is associated with a high risk over the
b. Personal history of low birth weight age of 7/8 years
c. Family history of ‘lazy eye’ d. Strabismic amblyopia treatment is associated with a high risk over the age
d. Family history of high long-sightedness of 7/8 years

5. Which one of the following is the best visual acuity test for detecting 11. Which one of the following statements about amblyopia treatment is most
strabismic amblyopia? accurate?
a. Single Sheridan-Gardiner letters a. Where there is a significant refractive error, the first stage of amblyopia
b. Single Lea pictures treatment is refractive correction
c. Crowded Lea pictures b. Patching should be started at the same time as the refractive correction
d. Cardiff acuity test c. Full-time occlusion should be started before part-time occlusion
d. Penalisation methods are much less effective than patching
6. Which of the following is the least significant reason for carrying out a
cycloplegic refraction in an 8 year old? 12. Which one of the following statements about incomitant deviations is
a. Decompensated exophoria at near incorrect?
b. Decompensated esophoria at near a. A superior oblique palsy usually causes most symptoms when the patient
c. Intermittent esotropia at distance looks down
d. Normal eye examination findings, but parental reports of a ‘turning eye’ b. A lateral rectus palsy usually causes most symptoms during near vision
c. A new incomitancy with predominantly horizontal diplopia is likely to be a
7. The following statements refer to the cover test. Which one is correct? lateral rectus palsy
a. It detects all forms of strabismus d. A new incomitancy with predominantly vertical diplopia is likely to be a
b. It is quite likely to have problems detecting convergence excess esotropia superior oblique palsy
c. It is quite likely to have problems detecting divergence weakness esotropia Please complete on-line by midnight on May 2 2007 -
d. It is quite likely to have problems detecting microtropia
You will be unable to submit exams after this date –
answers to the module will be published in our May 4 issue
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CET answers Course code: c-5196

These are the correct answers to Module 10 Part 3, which appeared in our March 9th, 2007 issue

1. Correct answer is C 7. Correct answer is C

A decompensated esophoria is the strongest indication of a need for a cycloplegic The required (incorrect) statement is: In exophoria, the fusional reserve that opposes
refraction in a young patient. the heterophoria is measured with base in prisms.

2. Correct answer is A 8. Correct answer is B

Metamorphopsia is the least likely symptom of decompensated heterophoria. Whether the patient prefers spectacles or contact lenses is the least important factor 47
to consider.

6/04/07 CET
3. Correct answer is C
Dyslexia is least likely to contribute to a heterophoria becoing decompensated 9. Correct answer is A
The required (incorrect) statement is: patients with accommodative insufficiency will,
on testing with flippers, be slower to clear plus lenses than
4. Correct answer is D they are to clear minus lenses.
The Mallett fixation disparity test detects the
presence of fixation disparity and measures 10. Correct answer is D
aligning prism or sphere. Decompensated exophoria at near is the easiest to treat with
fusional reserve exercises.
5. Correct answer is D
All of the above is the correct answer. 11. Correct answer is A
Dyslexia affects 5% of the population.
6. Correct answer is A
The fusional reserve that opposes the heterophoria 12. Correct answer is C
should be at least twice the heterophoria is the The required (incorrect) statement is: Meares-Irlen syndrome is
correct description of Sheard’s criterion. easily corrected with blue lenses.

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