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Binocular Balance

1. 2. 3. 4. Vertical Prism Dissociation Successive alternate occlusion Blurring technique ( Humphriss Immediate Contrast Binocular refraction

Vertical Prism Dissociation

Purpose
Purpose 1. To Equalize the Accommodation stimulus of two eyes. 2. To relax the accommodation of the two eyes.

Indication
Use only when both eyes have equal MSR VA. If MSR VA and accommodation are different between R and L eye use Prism dissociated Duochrome.

Procedure
1. 2. 3. 4. Fogging both eyes +1.00 Isolate a line of letters (~20/40) Put 3BU over OD and 3BD over OS Make sure PT can see 2 lines of letters, If not, Add more Prism equally for both eyes 5. Instruct Pt to compare 2 lines

Vertical Prism-Dissociation
Copy from ICEE note

Right eye: 3 BU Left eye: 3 BD Note: Equal amount of Prism in each eye

prism
Image

1 cm

1m
Base down

Objective

Copy from ICEE note

Binocular Prism Balance F Z B D E

Images are unequally blurred.

Images are equally blurred.

Procedure( cont.)
6. Give +0.25 to clearer eye( to blur the eye), until both eyes looks equal (Endpoint)
If the clearer eye still looks better after reduce the VA twice (give +0.50) should give -0.25 to the worse eye (to make the worse eye looks better)

7. After reach the Endpoint Binocular MPMVA

Binocular Prism Balance


RE(OD) LE(OS) +2.00 +3.00 +3.00 +3.00 +3.00 +2.25 +3.25 +3.50 +3.75 +3.50 Comment Initial spheres; VA at monocular endpoints: 20/20, 20/20 Fogging OU +1.00, Upper image looks clearer Equally blurred Upper image more blurred than lower image. remove prism start binocular MPMVA

Example 1. Balanced at RE +3.00 LE +3.50, indicating that the sphere difference should be 0.50 D, not 0.25 D as suggested by the monocular results Do the Binocular MPMVA.

Binocular Prism Balance


RE(OD) LE(OS) -1.25 -0.25 Plano +0.25 +0.25 +0.25 +0.25 -2.00 -1.00 -1.00 -1.00 -1.25 -1.50 -1.25 Comment Initial spheres; VA at monocular endpoints: 6/6,6/6Fogging both eyes +1.00, Lower image looks clearer Lower image still looks clearer Lower image still looks clearer Equal blurred Upper image looks clearer remove prism start binocular MPMVA

Example 2. Balanced at RE +0.25 LE -1.25 D. Do the Binocular MPMVA

If Not able to balance


Find the Dominant Eye and choose to make the dominant eye clearer. Use the lenses that provide the closest match.

Record
Binocular Balance + Binocular MPMVA OD +2.00-1.00x165 VA20/15 OS +2.00-1.00x010 VA20/15

Prism dissociated Duochrome


if the two eye did not reach equal VAs during their monocular refractions. there is reason believe that the acc differs in two eye.

Dissociated Duochrome Test


P
Z
D
T
A D

T
N B
A
H G
M X

T
B
O

P
N
A
G

Images seen simultaneously with 3 BU right eye 3 BD left eye Right eye sees the lower image, left eye the upper image.

Z
D
H T
D A

O
F
H

Red

Green

Blurred

F
B

H X M

P
Z
D
T

T
N B
A
H G
M X

T
B
O

P
N
A
G

K H N Z D B

D Z N H K

Z
D
H T
D A

Blurred Red Green

O
F
H

A D

F
B

H X M

K H N Z D B

D Z N H K

Each eye sees one chart. The red and green sides within each image are compared for clarity.

Copy from ICEE note

Dissociated Duochrome Test


Lenses Monocular end point : OD +1.75D OS +1.75D OD +1.50D OS +1.75DS OD +1.50D OS +1.75DS OD +1.50D OS +1.50DS OD +1.50D OS +1.25DS OD +1.50D OS +1.25DS Patient looks at: Patients response Action Lower image Red clearer Add 0.25D OD (OD) Lower image Upper image (OS) Upper image Upper image Lower image Red and green equal Red clearer Red clearer Red and green equal Red and green equal No change Add 0.25D OS Add 0.25DS OS No change (Confirming)

Binocular Balance
1. 2. 3. 4. Vertical Prism Dissociation Successive alternate occlusion Blurring technique ( Humphriss Immediate Contrast Binocular refraction

Successive alternate occlusion


Not use often Disadvantages:
Comparison under monocular condition No peripheral fusion lock Not for hyperopes, anisometropes, nytagmus pts.

Requires occluder

Procedure
Initial target:20/50 Fog +1.00D OU Compare OD to OS Ask pt Which is clearer? Give +0.25D to the clearer eye Endpoint= both eyes most equally clear Slowly add minus OU -> MPMVA

Alternate Occlusion Comparison Balance

Alternate occlusion with a hand-held occluder

Binocular Balance
1. 2. 3. 4. Vertical Prism Dissociation Successive alternate occlusion Blurring technique ( Humphriss Immediate Contrast Binocular refraction

Blurring technique
Can be used when VA is slightly unequal Have peripheral fusion lock Requires duochrome target Disadvantages:
Not for hyperopes Not everyone is good responder to Duochrome target

Procedure
Initial target: R/G target Minimal light Fog OS by +1.00D Red-side clear-> add-0.25D Green-side clear-> add+0.25D Endpoint= both sides equal or minimum minus lens-> green-side clearer or red-side clear Fog OD by +1.00D Unfog OS and perform test (Same endpoint criteria as OD) Fog OS by +1.00D Slowly add minus OU -> MPMVA

Binocular Balance
1. 2. 3. 4. Vertical Prism Dissociation Successive alternate occlusion Blurring technique ( Humphriss Immediate Contrast Binocular refraction

Binocular refraction
Have peripheral fusion lock More accurately determine cylinder axis Good for hyperopes, anisometropes, pt with nystagmus, binocular vision problem. OD and OS VAs must be 20/25 Performed after retinoscopy

Procedure
Initial Target: appropriate subjective refraction target. Fog OS until VA=20/50 Perform subjective refraction (initial sphere, JCC, refine sphere) on OD while OS is fogged Fog OD by +1.00D Perform refraction on OS Fog OS by +1.00D Slowly and minus OU -> MPMVA

Binocular balance (reti-binocular MPMVA)