The College of Optometrists

Examining and managing patients with an anomaly of binocular vision

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Sub-sections

Key points

  • You should assess the patient’s binocular vision as an integral part of a sight test.
  • You should use visual acuity tests that are appropriate for the age of the patient.
  • You should be aware of the options for treating patients with binocular vision anomalies.
  • If you treat a patient with patching you should have up-to-date knowledge and skills on this topic.
  • If you refer a patient for orthoptic or amblyopia treatment you should tell the patient about the likely treatment options.
  • You should exchange relevant information with other professionals if the patient is receiving care as part of a community service.

Principles of examining and managing patients with an anomaly of binocular vision

A182
You should assess the patient’s binocular vision as an integral part of a sight test because prescribing decisions for spectacles or contact lenses may affect the patient’s binocular status. For example, there can be a risk of over-minussing a young esophore or under-minussing a young exophore. 
A183
If you examine a patient who has an anomaly of binocular vision but they are asymptomatic and the anomaly is not amblyogenic, you may not need to correct the anomaly. In this case you should inform the patient, or their parent or carer, and advise them on the management option you think is most appropriate. A rare exception to this advice occurs if it is likely that an anomaly will worsen, for example decompensate, if left untreated.51 
A184
You should use visual acuity tests that are appropriate for the age of the patient,52 whenever possible using crowded tests. See section on Examining younger children
A185
You should be aware of the various options for treating patients with binocular vision anomalies. These include both refractive techniques and exercises; you should be able to advise the patient about these. 

References

51 Evans BJW (2007) Pickwell’s binocular vision anomalies. Oxford: Elsevier
52 Royal College of Ophthalmologists (2012) Guidelines for the management of strabismus in childhood [accessed 27 Nov 2013]

Amblyopia and patching

A186
When managing a patient with amblyopia, you should first correct any significant refractive error. This would typically follow a cycloplegic refraction.
A187
If you treat a patient with patching you should have up-to-date knowledge and skills on this topic. 
A188
You should ensure that patients with amblyopia are reviewed at appropriate intervals.
A189
If you design or deliver a treatment regime for the patient, you should ensure that the degree of patching is appropriate for the patient. 

When to refer

A190
You should be aware of the critical period for amblyopia development and ensure prompt treatment. You should refer children you do not feel competent to manage or whose visual acuity does not improve after a suitable period of time.  
A191
If you refer the patient for orthoptic or amblyopia treatment you should tell the patient about the likely treatment options. 

Community services

A192
If you are asked to refract a patient whom another professional is managing for their binocular vision anomaly you should exchange information on your findings with that professional. This is important because of the close relationship between accommodation and convergence and the effect that changes in prescription can have on the patient’s deviation.  
A193
If you have doubts about the effect a change in prescription may have on the patient’s ocular muscle status you should liaise with the co-managing professional before deciding what to prescribe. 

See sections on Consent and Safeguarding children and vulnerable adults.

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