1) The document provides information about identifying, investigating, and managing adult binocular vision disorders like heterophoria. It includes sample clinical cases and questions to test knowledge. 2) Dr. Sheila Rae is the author, with expertise in optometry, ophthalmic dispensing, myopia, and contact lenses. She teaches and researches in the area of vision and hearing sciences. 3) The clinical cases and questions relate to identifying heterophoria, investigating binocular vision status, and considering treatment options like exercises and refractive correction for managing heterophoria in adults.

1. VRICS
05/04/13VRICS
60
Visual Recognition
and Identification
of Clinical Signs
1 CET POINT
Visit www.optical.org for all the information about Enhanced CET requirements
Management options for adult
binocular vision disorders
Readers are encouraged to discuss the cases in this FREE VRICS
with their colleagues, conduct simple Internet searches, and use
the references provided to complete the Multiple Choice Questions
(MCQs). Please note that there is only one correct answer for each MCQ.
Complete the VRICS test online at: www.optometry.co.uk/cet/exams
Dr Sheila Rae, PhD, MCOptom, DipOrth
About the author
Dr Sheila Rae graduated from UMIST in ophthalmic optics and spent several years in clinical practice before completing a PhD at Anglia Ruskin
University, Cambridge, in 2007. Following this, she was appointed senior lecturer in the Department of Vision and Hearing Sciences at Anglia
Ruskin. She holds a College Higher Diploma in Orthoptics and teaches both optometry and ophthalmic dispensing students. Her research
interests are myopia, wavefront aberrations, contact lenses and clinical visual function. She is an examiner and assessor for the College of
Optometrists, a member of the British Standards Institute Committee for Ophthalmic Instrumentation and a fellow of the British Contact Lens
Association and the Higher Education Academy.
Binocular vision anomalies are commonly encountered in optometric practice. In adult patients,
we need to differentiate between the asymptomatic and symptomatic heterophorias which may
require management, for which there are a variety of approaches available depending on the
diagnosis. This VRICS tests practitioners’knowledge of identifying, investigating and managing
adult heterotropia conditions.
Course code C-30660 | Deadline: May 31, 2013
Learning objectives
Assess binocular status using objective and subjective means in
adult patients with heterophoria (Group 8.1.1)
Manages adult patients with heterophoria including
interpretation of test results and considering treatment options
such as exercises and refractive correction (Group 8.1.3)
APart 2: Heterophoria
Image D, page 62

2. 05/04/13VRICS
61
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2013 are now open. To nominate, visit
www.optometry.co.uk/awards
Reference to aid completion of the case
Weddell L (2010) Investigative techniques in binocular vision.
Optometry Today 50 (November 26): 37-45. (www.optometry.co.uk/
uploads/articles/nov-26-2010-cet.pdf)
Reference to aid
completion of the case
Evans BJW (2007) Binocular
vision anomalies: Part 1
symptomatic heterophoria.
Optometry Today 47 (March
9): 38-47. (www.optometry.
co.uk/uploads/articles/
CET9-03%20web.pdf)
MORE INFORMATION
•Exam Questions Under the new enhanced CET rules of the GOC, answers to MCQs for this exam must be submitted online. Please visit
www.optometry.co.uk/cet/exams and complete by midnight on May 31, 2013. You will be unable to submit exams after this date. Answers
will be published on www.optometry.co.uk/cet/exam-archive and CET points will be uploaded to the GOC on June 10, 2013. You will then
need to log into your CET portfolio by clicking on“MyGOC”on the GOC website (www.optical.org) to confirm your points.
•Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills – how will you
change the way you practice? How will you use this information to improve your work for patient benefit?
A
B
Which management option would be MOST appropriate
for the patient shown in Image B?
a Exercises to improve positive fusional reserves
b 3Δ base out prism, split between the eyes
c Pencil push up exercises
d Spectacles with low positive power to eliminate fixation
disparity at near
Which management option would be MOST appropriate
for the patient with the clinical data shown in Image A?
a Urgent referral to be seen by a neurologist
b Chavasse lens in the right eye of the reading spectacles
c Soon referral to be seen by an orthoptist
d Vertical and horizontal prism in the reading spectacles
Which of the following statements is CORRECT
regarding the test being performed in Image A?
a The patient should be asked to report the first
blurring of a target
b Diplopia with more than 3Δ of vertical prism is
a normal result
c An alternating cover test should be performed
d A single vertical line of letters is the most appropriate fixation
target
What is the MOST likely cause of the symptoms for
the patient with the clinical data shown in Image A?
a Decompensation of a longstanding incomitancy
b Monocular diplopia caused by cataract
c Acquired Brown’s syndrome
d Recent onset IIIrd nerve palsy
Which of the following statements is CORRECT regarding
the test being performed in Image B?
a The images of the two eyes are dissimilar so cannot be fused
b A 6Δ base up prism dissociates the eyes
c Tangent scales can be used at any near working distance
d Coloured filters would be used to dissociate the eyes
Which statement BEST describes the results of the test
shown in Image B?
a There is convergence insufficiency
b The gradient AC/A ratio is 6Δ per dioptre
c The heterophoria at 33cm is 15Δ esophoria
d The patient is unable to accommodate by 5D
Man, aged 74
RE +0.75 -0.75 110 6/9-
LE +1.75 -0.50 95 6/6+
DV CT 3Δ R/L 2Δ exophoria
6Δ R/L 8Δ exophoriaNV CT
Near vertical fusional reserve x/6/4
Intermittent diplopia for a few weeks,
covers one eye to read
Woman, aged 22
RE
LE +0.50 -0.25 10 6/5
+0.25 -0.50 180 6/5
DV CT Ortho
NV CT 5Δ esophoria
New job in factory, works at 25cm
Eyestrain and frontal HA later in day
01
02
03
04
05
06

3. VRICS
05/04/13VRICS
62
Visual Recognition
and Identification
of Clinical Signs
1 CET POINT
Visit www.optical.org for all the information about enhanced CET requirements
Reference to aid completion of the case
Evans BJW (2007) Binocular vision anomalies: Part 1 symptomatic
heterophoria. Optometry Today 47 (March 9): 38-47.
(www.optometry.co.uk/uploads/articles/CET9-03%20web.pdf)
References to aid
completion of the case
1. Evans BJW (2007) Binocular vision
anomalies: Part 1 symptomatic
heterophoria. OptometryToday 47
(March 9): 38-47. (www.optometry.co.uk/uploads/articles/CET9-03%20web.pdf).
2. Scheimann M et al. (2005) A Randomized ClinicalTrial ofVisionTherapy/Orthoptics versus
Pencil Pushups for theTreatment of Convergence Insufficiency inYoung Adults. Optometry
Vision Science 82:E583-E595. http://jpk.tjtc.edu.cn/07/yanjing/downshuangyuyuandi/8.%20
A%20Randomized%20Clinical%20Trial%20of%20Vision%20TherapyOrthoptics%20
versus%20Pencil%20Pushups%20for%20theTreatment%20of%20Convergence%20
Insufficiency%20inYoung%20Adults.pdf
C
D
Which of the following is NOT associated with the
condition shown in Image D?
a A near point of convergence of more than 10cm
b Accommodative insufficiency
c Near heterophoria greater than distance heterophoria
d Divergence excess exophoria
The nominations for the AOP Awards
2013 are now open. To nominate, visit
www.optometry.co.uk/awards
What is the MOST likely cause of the symptoms for
the patient with the clinical data shown in Image C?
a Acquired lateral rectus palsy
b V-pattern exophoria
c Base out prism induced by too wide optical centration of
the reading spectacles
d Decreased accommodative convergence when using
the reading spectacles
Which of the following statements about the
management of the patient with the clinical data shown
in Image C is MOST appropriate?
a The patient is likely to have prism adapted following a change
in fixation disparity after viewing through a prism
b Vision training will not work for this patient as he is presbyopic
c The reading addition should be increased to +2.00DS
d The optical centration of the reading spectacles should be
decreased by 10mm from the near PD to reduce the fixation
disparity
10
Which of the following statements about the
exercise shown in Image D is TRUE
a Diplopia of the far target will be more noticeable when
it is closer to the near target
b Physiological diplopia of the farther target acts as a
suppression check
c If diplopia of the near target is noted, the exercise
should be stopped
d The exercise should be performed monocularly
11
Which statement regarding the treatment of the
patient with the clinical data shown in image D is
CORRECT?
a Symptoms should resolve within four weeks of
treatment
b Positive fusional reserves and near point of convergence
should be improved
c Base-in prism would be effective
d Practice-based vision therapy is less effective than
home pencil push-ups
Man, aged 51
RE Plano - - 6/5
LE +0.50 -0.25 85 6/5
Near add +1.25 for 38cm
DV CT
NV CT 10Δ exophoria
3Δ exophoria
Near fixation disparity 2.5 Δ IN to align
Intermittent diplopia at near with new reading
spectacles
Woman, aged 19
RE -3.75 -1.00 10 6/5
LE -4.25 -1.50 165 6/5
DV CT
NV CT
3Δ exophoria
3Δ exophoria @ 40cm
Near point of convergence 18cm
Intermittent diplopia and frontal HA when
studying
07
08
Which of the following statements about the
exercise shown in Image C is TRUE?
a The direction of the stereoscopic effect shows whether
the patient is under or over-converging
b It can be used in the presence of suppression
c It exercises and improves the base in fusional reserves
d The increasing image separation requires decreasing
over-convergence
09
12