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Over the coming months, this series will look at four common binocular vision presentations. For each, the first article will describe clinical data, presenting signs. You will then be encouraged to think about the differential diagnosis and management options in practice which will then be described in detail.

There will also be a detailed summary of other relevant aspects of the condition.

Case 1
Presentation

A 22-year-old administrator presents with a history of frontal headaches almost daily while at work. These start by lunchtime and are aggravated if she has to use her VDU most of the morning. She also finds that words on the screen or on paper can blur or run together. Her symptoms appeared since she started a new job a month ago. Previously to this new job she had been travelling for a year.

POH: Never had spectacles or been seen by the hospital eye service

General and ocular health: Normal

Visions:

Dist: R 6/5 L6/5 Bin 6/5

Intermediate: R N5 L N5 Bin N5 at 55cm (VDU distance)

Near: R N4.5 L N4.5 Bin N4.5 at 30cm (habitual reading distance)

Refraction

R +0.25DS 6/5 N4.5

L +0.25 / -0.25 x 90 6/5 N4.5

Cover test:

Dist: Orthophoria

Int: 4∆ exophoria (moderate recovery)

Near: 4∆ exophoria (moderate recovery)

Motility: normal

Stereopis: 60" (TNO)

Fixation disparity (Mallett unit): Dist + Near: No slip

Near point of convergence: 20cm with effort (RE diverges)

Jump convergence to 15cm: difficult, movement of RE slow

Accommodation: R:9D L:9D Bin: 9.5D

AC/A ratio: 4∆/1D

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