Prism for-diplopia cybersight

Prism for-diplopia cybersight

• 1.
  Prescribing Prism for Diplopiain Neuro- Ophthalmic Disorders KELSEY MOODY MILESKI, OD, FAAO EMORY EYE CENTER ASSISTANT PROFESSOR OF OPHTHALMOLOGY SECTION OF OPTOMETRY
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   No financialdisclosures
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  Double vision  Seeing2 images of the same object
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  Double vision  Seeing2 images of the same object  Monocular  Refractive error  Cornea  Lens  Retina
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  Double vision  Seeing2 images of the same object  Monocular  Refractive error  Cornea  Lens  Retina  Binocular  Not bifoveal
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  Double vision evaluation History is KEY  BINOCULAR symptom  Direction  Duration  Location  Associated symptoms  History of eye turn or abnormal head position
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  Examination Tools/Techniques  Sensory Motor
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  Examination Tools/Techniques  Sensory Ability to have fusion  Worth-4 dot  Randot stereopsis  Motor
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – direction and duration  Alternating – magnitude and pattern
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  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
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration ESOTROPIA
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration EXOTROPIA
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration Left hypertropia
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – tells you direction and duration Left hypotropia or Right HYPERtropia
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Alternating – magnitude and pattern
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Alternating – magnitude and pattern
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  Examination Tools/Techniques  Prism Refracting surface that bends light  Used in patients with diplopia to move image to the eye
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  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
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  Examination Tools/Techniques  Covertesting  Prism  Esotropia: Base out  Exotropia: Base in  Hypertropia: Base down  Hypotropia: Base up
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  Examination Tools/Techniques  Covertesting  Prism  Esotropia: Base out  Exotropia: Base in  Hypertropia: Base down  Hypotropia: Base up
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  Examination Tools/Techniques  Covertesting  Prism  Esotropia: Base out  Exotropia: Base in  Hypertropia: Base down  Hypotropia: Base up
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  Examination Tools/Techniques  Covertesting  Prism  Esotropia: Base out  Exotropia: Base in  Hypertropia: Base down  Hypotropia: Base up
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  Examination Tools/Techniques  Covertesting  Prism  Esotropia: Base out  Exotropia: Base in  Hypertropia: Base down  Hypotropia: Base up
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  Examination Tools/Techniques  Covertesting  Prism  Esotropia: Base out  Exotropia: Base in  Hypertropia: Base down  Hypotropia: Base up
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  Examination Tools/Techniques  Sensory Motor  Ductions/Versions  Cover testing or Maddox rod  Unilateral – direction and duration  Alternating – magnitude and pattern
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  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
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  Examination Tools/Techniques  Sensory Worth 4-dot  Randot  Motor  Ductions/Version  Cover test or Maddox rod  Exophthalmometry  Lid evaluation  Double Maddox rod
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  Treating Double Vision Rule out pathologic cause  Neuro-imaging  Bloodwork  Nonsurgical  Surgical
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  Treating Double Vision Nonsurgical  Prism  Fresnel – temporary fix  Ground- in – permanent  Occlusion  Patching  Bangarter foils
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  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
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  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
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  Treating Double Vision
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  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
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  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
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  Diplopia Differential: Muscle 1.Elevation 2. Intorsion 3. Adduction 1. Adduction 1. Depression 2. Extorsion 3. Adduction 1. Extorsion 2. Depression (on abduction) 3. Abduction 1. Abduction 1. Intorsion 2. Depression (on adduction) 3. Abduction
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  Diplopia Differential: Nerve 1.Elevation – SR and IO 2. Depression – IR 3. Adduction – MR 4. Eyelid elevation: levator 5. Pupil: constriction 1. Intorsion 2. Depression (on adduction) 3. Abduction 1. Abduction
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  Diplopia Differential: Neuromuscular Junction MyastheniaGravis
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  Double Vision Differential:Brain Dinkin M. Diagnostic Approach to Diplopia. Continuum (Minneap Minn) 2014;20(4):942-965
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  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
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  Treating Neurologic Conditionswith 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
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  Horizontal prism 1. Startwith 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
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  Vertical prism 1. Startwith 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
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  Horizontal + VerticalPrism 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
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  Treating Neurologic Conditionswith 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
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  Treating Neurologic Conditionswith 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
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  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
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  Yoked prism?
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  Yoked prism?  Visualneglect  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
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  Prism challenges  Otherocular 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
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  CASES
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  Case 1 54 yearold 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
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  Case 1 OD OS BCVA20/25-1 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
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  Case 1
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  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
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  Case 1: POLL 54year 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
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  Case 1  Startedwith 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
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  Case 1  Fitwith 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
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  Case 1 Axial T1 MRIw/o contrast Axial T1 MRI w/ contrast
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  Case 1  4-monthF/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
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  Case 1  8-monthF/U visit
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  Case 1  Fitwith 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
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  Case 1  4month F/U  Finished radiation 1 month and 10 days ago  Hopeful for ground-in prism.- took off 20 BO Fresnel and still diplopic
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  Case 1  Fitwith 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
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  Case 2
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  Case 2  72year 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
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  Case 2  Ocularhistory:  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
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  Case 2 OD OS BCVA20/30-2 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
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  Case 2 Near
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  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
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  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
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  Case 2  Updatedglasses 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
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  Case 2 72 yearold 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
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  Case 3
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  Case 3 55 yearold female with double vision and headache  Chief complaint: double vision  Started 3 days ago while driving  Constant  Associated symptoms  Mild blurry vision OD  Headache  Ocular history: Dry eye OU  Systemic history: diabetes (HbA1c 5.8%), hypertension (200/131), asthma  Medications: albuterol, amlodipine, aspirin, atorvastatin, duloxetine, hydrochlorothiazide-losartan, metformin, nortriptyline, zantac  Surgical history: spinal stimulator, hemorrhoidectomy, C-sectionx2  Allergies: latex, codeine, penicillins, sulfadiazine  Social history: unremarkable
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  Case 3 OD OS BCVA20/25 20/20 Color Vision 14/14 14/14 Pupils 4.25→3.00mm; sluggish 4.25→3.50mm; brisk Confrontation fields Full to finger count Full to finger count IOP 13 mmHg (iCare) 12 mmHg (iCare) Anterior segment 1+ NS 1+ NS Posterior segment Unremarkable Unremarkable Palpebral aperatures 10mm 7mm
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  Case 3
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  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
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  Case 3: POLL 55year 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
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  Case 3  Startedwith 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
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  Case 3 55 yearold 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!
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  Case 3  1month f/u
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  Case 3  2month f/u
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  Clinical Pearls • Prismcan 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