The College of Optometrists

regarding the case senario of this eldery gentleman. What would be the management for his exo slip at near?

some thought of mine.... He has not come in with symptoms of a decompensating exo at near, however it may have been induced by the extra plus he has been given. If he was younger my first thought would be to give him so exercises - but is that suitable for px of this age group (80's) Are prisms the only option? Can you leave him without correcting it with prisms, maybe he has had it always, and is not symptomatic, why rock the boat?

My exams are in December, so quick feedback is appreciated!!

yes - I like your thoughts - spot on. You notice that he has a high reading add - and he would have to hold the book abit closer than normal to read properly.

To Fixation unit would have to be held closer - just like the book. So it is no surprise he has abit of slip at near - he is exercising his converghence more.

Most optoms would give him the prism - exercises would not work 'cos, (1) he has other ocular conditions holding his vision back, (2) he has good convergence (12cm) (which is exercisable) - but as it tires - the exo slip appears (which is not exercisable)

Notice they claim he has accomodation -but at his age he has not - they are simply measuring his depth of focus -so he has small pupils (so you would want to dilate to view his fundus).

His distance Rx is unchanged - but the reading Rx is increased to help his reading.

Despite his controlled hypertension - his retinae shows little signs - doesn't it. He has macula changes so you may like to advise him about suppliments and leutin. He has quite alot of cataract and that would cause him glare with risks of trips and falls. He may benefit from his cataracts being treated and you would want to discuss this with him.

You would have to beable to understand the macula here - so you don't claim that he has wet AMD. It is dry - why? Because the RP is slightly disorganised, but the macula is flat as shown by the little vessel going onto it. He has no metamorphopsia and has no pigment. The drusen are obviously hard by their size and position.

There is my ideas! Hope they help steve

Thank you

Thank you. Can you please clarify your statement regarding.... 'but as it tires - the exo slip appears (which is not exercisable)'

Am I incorrect to say that slips found by fixation disparity (with px with phorias) are due to decompensating phorias. Do exercises not help deompensating phorias???

Oh, what I was meaning that at a normal reading distance he may not have any fixation disp. But as he is using a stronger add at a closer distance it may well tire is convergence and show FD.

Yes to the second part of yr question, but not always. I remember hearing in a lecture once that Fd could appear even when there was no phoria or - paradoxically - the phoria was the other way round. So you could get 2 eso phoria and 1 exo FD in the same person - I think that it is also mentioned in Pickwell (but I can't find my book to check). In that respect all FD is showing, is the stress on the bino system of holding Single bino vision. Certainly, it seems true - you can find people who need prisms and no amount of exercises will reduce their dependancy on prisms. Interesting question! Any more? -happy to help steven