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Prism for-diplopia cybersight
1. Prescribing Prism for
Diplopia in Neuro-
Ophthalmic Disorders
KELSEY MOODY MILESKI, OD, FAAO
EMORY EYE CENTER
ASSISTANT PROFESSOR OF OPHTHALMOLOGY
SECTION OF OPTOMETRY
4. Double vision
Seeing 2 images of the same object
Monocular
Refractive error
Cornea
Lens
Retina
5. Double vision
Seeing 2 images of the same object
Monocular
Refractive error
Cornea
Lens
Retina
Binocular
Not bifoveal
6. Double vision evaluation
History is KEY
BINOCULAR symptom
Direction
Duration
Location
Associated symptoms
History of eye turn or abnormal head position
10. Examination Tools/Techniques
Sensory
Motor
Ductions/Versions
Cover testing or Maddox rod
Unilateral – direction and duration
Alternating – magnitude and pattern
11. Examination Tools/Techniques
Sensory
Motor
Ductions/Versions
Cover testing or Maddox rod
Unilateral – direction and duration
Alternating – magnitude and pattern
When eye is covered, it will move to resting position
ESOTROPIA - EYE RESTS IN
EXOTROPIA – EYE RESTS OUT
HYPERTROPIA – EYE RESTS UP
HYPOTROPIA – EYE RESTS DOWN
17. Examination Tools/Techniques
Sensory
Motor
Ductions/Versions
Cover testing or Maddox rod
Unilateral – tells you direction and duration
Left hypertropia
19. Examination Tools/Techniques
Sensory
Motor
Ductions/Versions
Cover testing or Maddox rod
Unilateral – tells you direction and duration
Left hypotropia or
Right HYPERtropia
23. Examination Tools/Techniques
Prism
Refracting surface that bends light
Used in patients with diplopia to move image to the eye
IMAGE MOVES TOWARDS THE APEX
TO MEASURE:
PUT APEX TO WHERE THE EYE IS
30. Examination Tools/Techniques
Sensory
Motor
Ductions/Versions
Cover testing or Maddox rod
Unilateral – direction and duration
Alternating – magnitude and pattern
31. Examination Tools/Techniques
Sensory
Motor
Ductions/Versions
Cover testing or Maddox rod
Subjective response from patient
Exo and hyper’s are crossed
Eso and hypo are uncrossed
Biousse V, Newman NJ Neuro-ophthalmology Illustrated 2nd ed New York : Thieme; 2016:349-
350
32. Examination Tools/Techniques
Sensory
Worth 4-dot
Randot
Motor
Ductions/Version
Cover test or Maddox rod
Exophthalmometry
Lid evaluation
Double Maddox rod
33. Treating Double Vision
Rule out pathologic cause
Neuro-imaging
Bloodwork
Nonsurgical
Surgical
35. Treating Double Vision
Prism
Goal is binocular vision in primary gaze
Apex of prism is where the eye is
Exotropia: base in prism
Esotropia: base out prism
Right hypertropia: base down prism
Right hypotropia: base up prism
May need 2 pairs of glasses if deviation is different at distance and near
36. Treating Double Vision
Fresnel prism
Press-on lens for alleviation
of diplopia
Can use initially to
determine if patient can
adapt to prism
Good to use if etiology is still
under investigation or
alignment may change
Advantages
Can be put on glasses
immediately in clinic for
relief
Easy to change
Lightweight
Can be prescribed up to 40
PD! – Ideal for large
deviations
Inexpensive
Disadvantages
Blur
Only use in front of one
eye
Visible
Hard (but possible) to
correct both horizontal and
vertical deviations
simultaneously
38. Treating Double Vision
Ground-in prism
Prism built into glasses
prescription
Good to use when
deviation is stable
Advantages
Two clear lenses
Can be split between
right and left eye to
make lenses symmetric
Not easily visible
Easily corrects vertical
and horizontal
Disadvantages
Can only make up to 20
PD total
Time to be made
Expensive
May need multiple
changes
39. Treating Double Vision
Occlusion
Goal is monocular
vision to alleviate
diplopia
Advantages
Diplopia resolves in
all positions of gaze
No additional
glasses needed
Immediate relief
Inexpensive
Disadvantages
Cosmesis
Lack of binocular
vision
43. Double Vision Differential: Brain
Dinkin M. Diagnostic Approach to Diplopia. Continuum (Minneap Minn)
2014;20(4):942-965
44. Double Vision Differential
Brain
Internuclear ophthalmoplegia
Gaze palsy
Skew deviation
Dorsal midbrain syndrome
Neurodegenerative disease
Nerve
CN III
CN IV
CN VI
Neuromuscular junction
Myasthenia gravis
Muscle
Thyroid eye disease
Orbital fracture
Orbital mass
Inflammation
45. Treating Neurologic Conditions with
Prism
Assuming etiology is known or under investigation…
1. Update refraction at distance and near
2. Cover test/Maddox rod without Rx in all positions of gaze at distance
3. Cover test/Maddox rod at distance and near with Rx
4. Trial prism at distance and near
46. Horizontal prism
1. Start with ½ objective measurement and move bar up until fusion
1. Can be placed over either eye
1. Needs to be placed over the paretic eye only if need to move the image to be able
to fixate on it
2. Move bar up and down by 2 PD until fusion breaks – median point is end point
3. Recheck fusion
47. Vertical prism
1. Start with objective measurement and move bar up until fusion
1. Can be placed over either eye
1. Needs to be placed over the paretic eye only if need to move the image to be able
to fixate on it
2. Move bar up and down by 1-2 PD until fusion breaks – median point is end point
3. Recheck fusion
48. Horizontal + Vertical Prism
1. Neutralize larger deviation first (will still be diplopic)
1. Goal: Move image until they are lined up vertically or horizontally
2. Add in second prism over fellow eye
3. If end point is difficult, trial frame Rx and prism and make small changes (1
PD)
4. Can be challenging and time consuming but obtainable
49. Treating Neurologic Conditions with
Prism
Start with Fresnel first
Etiology unknown
Deviation may change
Consider ground-in prism
If any deficit remains
Once deficit is stable
Consider referral for surgical intervention
50. Treating Neurologic Conditions with
Prism
When to refer for surgery
Constant diplopia
Cover testing has been stable for ~1 year
Unlikely to progress
Not undergoing treatment, etc.
Able to achieve fusion with prism
Instead of moving the image to the eye, surgery moves the eye to the image
If unable to fuse with prism, likely won’t be able to fuse after surgery
Goal is single vision in primary gaze – may still be diplopic in other gazes
51. Yoked prism?
Goal: move the image out of defect
Hemianopsia
Nystagmus
Abnormal head posture
Generally a 2 D prism shifts the image by 1 degree
Max 20PD in ground-in glasses
Shift the field by only 10 degrees
Higher amounts with Fresnel
Will require 2 in front of each eye which creates blur and distortion
Better to place sectorially
53. Yoked prism?
Visual neglect
Common in right brain stroke
Patients ignore left side
Turn head to right
Extinction phenomenon when presented with simultaneous stimulus
Prism adaption
Yoked prism to right and perform exercises
Overcompensate to the right
With practice, adapt
Remove prism and naturally move into neglected field
54. Prism challenges
Other ocular comorbidities
Maculopathies
Asymmetric visual acuity
Glaucoma and/or other visual field defects
Not wanting to come out of progressive lenses or have separate glasses
>40D of prism needed
Nystagmus
Suppression
56. Case 1
54 year old male with blurred vision and eye fatigue x 2.5 years
Chief Complaint: Blurry vision:
Gradually worsening at distance with driving and looking to the left
Double vision in the evening and when he turns his face to shave
With and without glasses on
Ocular history: myopia
Systemic history: Hypercholesterolemia, depression
Medications: Atorvastatin, duloxetine
Allergies: NKDA
Social history: Current every day smoker x 27 years
57. Case 1
OD OS
BCVA 20/25-1 20/20
Glasses -2.25+0.50x105 ADD: +2.00 -2.50+0.50x007 ADD: +2.00
Refraction -1.75 ADD: +2.25 -2.50+0.50x178 sph ADD: +2.25
Pupils 5.00→4.00mm 5.00→4.00mm
Confrontation fields Full to finger count Full to finger count
IOP 15 mmHg (iCare) 12 mmHg (iCare)
Exophthalmometry 23mm 22mm
Anterior segment Unremarkable; (-)ptosis Unremarkable; (-)ptosis
Posterior segment Unremarkable Unremarkable
59. Case 1
Diagnosis: LEFT ABDUCTION DEFICIT
Differential
CN VI palsy
Brain
Intracranial course
Myasthenia gravis
Thyroid eye disease
Orbital mass
Duane’s retraction
Pertinent Findings
ISOLATED
No other cranial neuropathies
No horner’s syndrome
No papilledema
No proptosis
No ptosis
No fatiguability
GRADUAL CHANGE OVER LAST 2.5 YEARS
60. Case 1: POLL
54 year old male with blurred vision and eye fatigue x 2.5 years
What type of prism would you like to prescribe?
1. Base in Fresnel prism
2. Base out Fresnel prism
3. Base in ground-in prism
4. Base out ground-in prism
61. Case 1
Started with 6 BO prism
Still diplopic
Increased prism to 10 BO to obtain fusion
Improved clarity when increased to 12 BO
Blurrier when increased to 14 BO
62. Case 1
Fit with 12 BO Fresnel prism
Needs temporary fix
Able to tolerate at distance and near
Order MRI of the brain and orbits W/W/O contrast
64. Case 1
4-month F/U visit
Referred to neurosurgery
MRI monitoring vs radiotherapy
Plans to monitor with MRI only
Motility and cover testing stable
Bothered by cosmesis of Fresnel and requests ground in prism
66. Case 1
Fit with 20 BO Fresnel prism OVER GROUND IN PRISM (12 BO)
Needs temporary fix
Able to tolerate at distance. Will remove glasses for reading
Refer to radiation oncology
F/U after treatment
67. Case 1
4 month F/U
Finished radiation 1 month and 10 days ago
Hopeful for ground-in prism.- took off 20 BO Fresnel and still diplopic
68. Case 1
Fit with 12 BO Fresnel prism OVER GROUND IN PRISM (12 BO)
24 BO too much for ground-in prism
Refer for strabismus surgery consult
Educated that surgery will not be recommended for several months
70. Case 2
72 year old male with CC of blurred vision OD and OS
Notes hard time looking up and down
Problems reading small print like the newspaper
Also problems seeing TV controls
He had gone through a few pairs of glasses without improvement
Current glasses are progressives
71. Case 2
Ocular history:
Cataract OD/OS
Dry eye syndrome OD/OS
Ophthalmic meds: none
Systemic history:
Arthritis
Atrial fibrillation
Hypertension
Hypercholesterolemia
Obstructive sleep apnea
Progressive supranuclear palsy
Medications
Allegra
Amlodipine
Carvedilol
Eliquis
Furosemide
Losartan
Lovastatin
Memantine
Allergies:
NKDA
Surgical history:
Joint replacement: hip and
knee
Hernia repair
Family history:
Hypertension: mother and
father
Social history
Social alcohol
Former smoker: Quit 33 years
ago
72. Case 2
OD OS
BCVA 20/30-2 PH: 20/20 20/25 PH: 20/20
Pupils Equal, round, reactive to light; no RAPD
Confrontation Fields Normal Normal
Motility Restricted Restricted
IOP 14 15
NPC Reduced at 20 cm
74. Case 2
OD OS
Eyelids
2+ blepharitis and
vascularization
2+ blepharitis and
vascularization
Cornea
Tear debris
1+ SPK
Tear debris
1+ SPK
Lens 1-2+ NS 1-2+ NS
Optic disc 0.30/0.30 0.35/0.35
Retina Normal Normal
75. Case 2 POLL
Diagnosis: Convergence insufficiency in the setting of Progressive Supranuclear Palsy
Work-up: Not needed
What type of prism would you like to prescribe?
1. Base in Fresnel prism
2. Base out Fresnel prism
3. Base in ground-in prism
4. Base out ground-in prism
76. Case 2
Updated glasses Rx and trial framed near Rx
Started with 10 BI prism at near
Still diplopic
Increased prism to 14 BI to obtain fusion
Blurrier when increased to 12 BI or decreased to 16 BI
Yoked prism attempted but no benefit
Trialed 2 BI prism at distance and uncomfortable
77. Case 2
72 year old male with blurry vision
Take out of progressive lenses
Fit with 14 BI ground-in prism in NVO
Hold reading material higher
Aids to bring reading material higher
Prescribed DVO without prism
F/U in 4-6 weeks
82. Case 3
Diagnosis: Exotropia and hypertropia OS
Differential
CNIII palsy
CN VI palsy
INO
Skew deviation
Myasthenia gravis
Orbit
Thyroid eye disease
IOIS
GCA
Pertinent Findings
3 mm ptosis, anisocoria and diplopia
No proptosis
Pain
83. Case 3: POLL
55 year old female with double vision and headache
What type of prism would you like to prescribe?
1. Base in Fresnel prism
2. Base out Fresnel prism
3. Base down Fresnel prism
4. Occlusion
84. Case 3
Started with 8 BI rotated clockwise in front of left eye to correct
hypotropia
Still diplopic – diagonal
Increased to 10 BI rotated clockwise in front of left eye
Fusion in primary gaze but diplopic with small eye movements
85. Case 3
55 year old female with double vision and headache
Recommend occlusion
Non-comitant
Unable to fuse with prism
Concern for CN III with pupil involvement
Order CTA head to rule out PCOM aneurysm and MRI brain and orbits W/W/O
contrast
Pending normal imaging consider work-up for MG
Neuro-imaging NORMAL!
88. Clinical Pearls
• Prism can be challenging and time consuming
• Schedule appropriate time slots
• Look for neuro-ophthalmic etiology is patient has not undergone work-
up
• Set patient expectations for prism
• Always bring the patient back for follow-up
• Check to make sure glasses were made correctly
• Don’t be afraid to make changes
• It’s okay to sometimes recommend occlusion
• Eye patch, bangarter or occlusion CL
89. References
Cornblath WT. Diplopia due to ocular motor cranial neuropathies. Continuum (Minneap
Minn) 2014;20(4):966-980
Dinkin M. Diagnostic Approach to Diplopia. Continuum (Minneap Minn) 2014;20(4):942-
965
Eggenberger ER. Supranuclear eye movement abnormalities. Continuum (Minneap Minn)
2014;20(4):981-992
Nerrant E, Tilikete C. Ocular Motor Manifestations of Multiple Sclerosis. J Neuroophthalmol.
2017 Sep;37(3):332-340
Peragallo JH, Newman NJ. Diplopia-An Update. Semin Neurol. 2016 Aug;36(4):357-361
Tamhankar MA, Biouuse V, Gui-Shuang Y, et al. Isolated third, fourth and sixth cranial
nerve palsies from presumed microvascular versus other causes: a prospective study.
Ophthalmology. 2013 Nov; 120(11):1-13