Anomalies of vergence and their management, MCQs

1. Anomalies of Accommodation
and Vergence
By - Krishna Banjade
Consultant optometrist
M. Optom
FLVPEI - Pediatrics and BSV

2. Which prism is used for testing vergence facility ?
a. 12BI 3BO
b. 10BO 3BI
c. 12BI 6BO
d. 12BO 3BI

3. Which one of the following is a BV anomaly which
is likely to cause reading problems for a 7 year old?
a.15 prism dioptre hypotropia
b. Vergence dysfunction
c. An uncorrected refractive error of -2.50DS
d. Suppression
e. Amblyopia

4. Which one of the following is a good guide to
degree of compensation of a heterophoria?
a. Direction of movement during recovery
b. Size of recovery
c. Rate of recovery
d. Size of the heterophoria
e. Direction of the heterophoria

5. Which of the following statements is true about
the use of prism to treat binocular vision
disorders?
a. When prism is prescribed to treat an esodeviation, we do not
expect the eye to change alignment through the prism
b. Base out prism is used to treat exodeviations
c. The goal of prism correction is to increase the compensatory
fusional reserve
d. Prism is more useful with horizontal than with vertical
deviations

6. Convergence insufficiency
• AC/A – Low
• NPC – Receded
• NPA – Normal
• NRA/PRA – Low NRA
• NFV/PFV – Low PFV
• Vergence facility - Low BO
• BAF/MAF – Fails + / Normal
• MEM - Low

7. Convergence Excess
• AC/A – High
• NPC – Normal
• NPA – Normal
• NRA/PRA – Low PRA
• NFV/PFV – Low NFV
• Vergence facility - Low BI
• BAF/MAF – Fails + / Normal
• MEM - High

8. Acccommodative Insufficiency
• AC/A – Normal
• NPC – Normal
• NPA – Low
• NRA/PRA – Low PRA
• NFV/PFV – Low PFV for near
• Vergence facility - Normal
• BAF/MAF – Fails -
• MEM - High

9. Accommodative Excess
• AC/A – Normal
• NPC – Normal
• NPA – Normal
• NRA/PRA – Low NRA
• NFV/PFV – Low NFV for near
• Vergence facility – Normal
• BAF/MAF – Fails +
• MEM - Low

10. Fusional vergence dysfunction
• AC/A – Normal
• NPC – Normal
• NPA – Normal
• NRA/PRA – Low NRA and PRA
• NFV/PFV – Low NFV and PFV
• Vergence facility - Low BI and BO
• BAF/MAF – Fails + / -
• MEM - Normal

11. Divergence insuffeciency
• AC/A – Low
• NPC – Normal
• NPA – Normal
• NRA/PRA – Normal
• NFV/PFV – Low NFV
• Vergence facility - Low BI
• BAF/MAF – Normal
• MEM - Normal

12. Divergence Excess
• AC/A – High
• NPC – Normal
• NPA – Normal
• NRA/PRA – Normal
• NFV/PFV – Low PFV
• Vergence facility - Low BO
• BAF/MAF – Normal
• MEM - Normal

13. A 12 year old boy presented with a history of blurred vision after 5-10 minutes of
reading, along with a report of eyestrain. Initial history and testing to consider
non-functional causes were negative
• VA(Dist, uncorrected): OD: 20/20, OS: 20/20
• VA(Near, uncorrected): OD: 20/20, OS: 20/20
• NPC: Penlight: 1"/2"
• Cover Test (Distance): ortho
• Cover test (Near): 4 esophoria
• Subjective: OD: plano, OS: plano
• Base In Vergence (Distance): X/7/4
• Base Out Vergence(Distance): 9/18/12
• -1.00 Gradient: 8 ESO
• Base In Vergence (Near): 10/19/11
• Base Out Vergence(Near): 12/22/10
• Vergence facility: 10 cpm
• Acc amp: OD: 13D, OS: 13D
• PRA: -2.50 NRA: +1.50
• MAF OD: 0 cpm fails +2.00
• OS: 0 cpm fails +2.00
• BAF: 0 cpm fails +2.00
• MEM: plano
Tests probing ability to relax acc are low:
+ ON BAF
+ ON MAF
+ NRA
Accommodative Excess
Diagnosis ?
Treatment ?
Is plus appropriate?
Patient is rejecting plus based on testing
Best treatment is VT

14. A 20 year old college student presented with complaints of blurry
vision and discomfort around his eyes after 15 minutes of reading.
• VA(Dist, uncorrected): OD: 20/20, OS: 20/20
• VA(Near, uncorrected): OD: 20/20, OS:20/20
• Near Point of Convergence: Penlight: 2"/3"
• Cover Test (Distance): ortho
• Cover test (Near): 4 esophoria
• Subjective: OD: plano
• OS: plano
• Near lateral Phoria: 4 eso
• -1.00 Gradient: 8 eso
• Base In Vergence (Near): 10/18/10
• Base Out Vergence(Near): 12/23/11
• Vergence Facility: 9 cpm
• NRA: +2.50
• PRA: -1.00
• Acc amp: OD: 5D, OS: 5D
• MAF: OD: 0 cpm, can't clear -2.00
• OS: 0 cpm, can't clear -2.00
• BAF: 0 cpm, can't clear -2.00
• MEM: +1.25
Diagnosis ?
Accommodative Insufficiency
Prescribe glasses ? How much ?
NRA = +2.50
PRA = -1.00
2.50 - 1.00 = 1.50
1.50/2 = +0.75
MEM = +1.25
Normal MEM is about +0.50
(1.25-0.50 = 0.75)
ADD should be about +0.75 to
+1.00

15. An 18 year old presented with complaints of inability to read comfortably for
more then 10 minutes. After 10 minutes her eyes burn, the print becomes
below and if she continues she experiences double vision.
• VA(Dist,uncorr): OD: 20/20, OS: 20/20
• VA(Near, uncorr: OD:20/20, OS: 20/20
• NPC: Penlight: 2"/3"
• Cover Test (Dist): ortho
• Cover test (Near): 6 esophoria
• Subjective: OD: plano, OS: plano
• Near lateral Phoria: 6 ESO
• -1.00 Gradient: 13 esophoria
• Base In Vergence (Near): 4/6/-2
• Base Out Vergence(Near): 18/28/16
• NRA: +2.50
• PRA: -0.50
• Acc amp(push up): OD: 13D, OS: 13D
• MAF: OD: 12 cpm, OS: 12 cpm
• BAF: 0 cpm, diplopia with -2.00
Diagnosis ?
Convergence Excess
Treatment ?
1. Glasses
2. Vision Therapy

16. A 15 year old 10th grader presented with a history of asthenopia
associated with short periods of reading.
• VA(Dist, uncorr): OD: 20/20, OS: 20/20
• VA(Near, uncorr): OD: 20/20, OS: 20/20
• NPC: Penlight: 1"/2"
• Cover Test (Dist): ortho
• Cover test (Near): 2 exophoria
• Subjective: OD: plano, OS: plano
• Near lateral Phoria: 2 EXO
• -1.00 Gradient: 2 ESO
• Base In Vergence (Near): 6/10/4
• Base Out Vergence(Near): 4/8/6
• NRA: +1.50
• PRA: -1.25
• Accomm amp: OD: 13D,OS: 13D
• MAF OD: 12cpm,OS: 12cpm
• BAF: 2 cpm, difficulty with both +/-2.00
Diagnosis ?
Fusional Vergence Dysfunction
Treatment ?
Vision Therapy