By George, He’s Got It!

Here’s George.  You might call him a geriatric patient because of his age, but he is spry and his sense of humor hasn’t lost a beat.  Yet over the past few years he’s been progressively bothered by double vision.  His optometrist referred George to me because he was already up to 12^ base out in his glasses with 2^ vertical, with no end in sight to chasing prism.  I’m not opposed to prism, by any means, though I view it as a support that positions a patient to succeed more readily in undertaking active therapeutic procedures.  As you can see, when George is asked to fixate a distance target or read the acuity chart, he adopts a position with his chin upward, allowing him to maintain his eyes in a relatively downward position.

As it turns out, or perhaps more appropriately as it turns in, George has an “A” pattern esotropia.  I couldn’t find a convenient graphic of one, so I inverted this web image of a “V” pattern eso.  The “A” is derived as a simple way of describing that the inward drift is greater in superior gaze as compared to either primary or inferior gaze.  George’s non-comitancy isn’t of sufficient cosmetic magnitude to show up photographically, but it is clear that he maintain his chin up posture because his best position of fusion, or least eso, is with his eyes looking downward.

George has made really nice strides in gaining fusion without the need for prism.  As I reviewed his progress with him, our Resident, and a new extern, he was highly appreciative of the gains made thus far in vision therapy.  He has bolstered divergence as well as vertical fusion ranges, and developed greater peripheral awareness in the lateral field.   “I have to tell you that when I started therapy I was skeptical”.  “That’s fine, George” I told him.  “Before you were a healthy skeptic and now you’re simply healthy.”  We all agreed that success in vision therapy is very much a function of the extent to which a patient meaningfully participates.

There were a few other issues we talked about, now that we’re mid-way through George’s therapy program.  Delighted that he can now walk around without glasses, he was thinking of getting a bilateral lid tuck.  It’s possible that because he was walking around with his chin up so regularly for the past few years, George’s bilateral ptosis was partly functional.  Or it may have been purely mechanical due to aponeurosis or dehiscence of the levator muscles.

Here’s the visual field of a patient with significant ptosis causing an artifactual loss of the superior visual field.  When George mentioned that he was thinking of “having his lids done”, I asked him if experienced dry eye symptoms and he said that he did, indeed, and was loading up on fish oils.  We briefly discussed the potential risk of blepharoplasty, or a lid tuck, in exacerbating dry eye symptoms.  While Medicare would pay for the procedure with documentation of what a repeat fields with his lids taped up would do to increase the visual field, George now has something else to ponder.

– Leonard J. Press, O.D., FCOVD, FAAO


4 thoughts on “By George, He’s Got It!

  1. Dr Press,
    How i admire the GIANTS in Vision Therapy and you are one of them! You may have heard that i am the one with Guillen -Barre Syndrome and am disabled at this point. And after that being said i wonder if you tried using large projected quoits or other pic while the head is down and slowly pull chin down. Or try high bo proj quoits at distance and slowly try to reach bi. Rock in/out. Or while trying that place BDown prism over both eyes while he is trying to fuse bi at low amounts.

  2. Thanks for the kind words, Roxanne. Excellent suggestions and yes – we have used these approaches. We have used BD yoked ^ in therapy, and have also had George consciously move his chin slowly downward while trying to maintain fusion. We use multiple positions of gaze, and a variety of fusion target sizes and distances, with varying degrees of stereopsis. Hope you are doing better, and best wishes.

  3. Dr Press,
    George does not need a Blepharoplasty as that would make his eyes female looking; but a chin tuck would be nice.
    My question regards nasal occlusion as the 2 prism vertical could be an artifact, but the esotropia worsens over time; did we rule out TED and Stroke. If so the Visual Therapy is the answer, but muscle surgery could get
    the Visual Therapy in the ball park?
    Well, just comments. But, if you were to do nasal occlusion which lens or both and where would you place it. Or, is George attempting to go without glasses, even though Plus should help his eso problem.

  4. Good observation. George has a spherical equivalent of -1.50 unaided in both eyes – so he gets a plus lens effect by leaving his Rx off. He is quite happy at present functioning without an rx for most visual tasks. As we know, 20/.20 is overrated (one only needs 20/50 in one eye to drive in most states, and newspaper print demand is only 20/50). He was tied to the prism before, but now can function well without it. His 2^ vertical isn’t likely an artifcact with such a relativeliy small horizontal imbalance, and we’ll continue to work his vertical vergence ranges as well.

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