Case History: The Key to Understanding Binocular Vision Problems

From the start of Optometry school, professors and supervisors preached that a patient’s chief complaint and case history should direct your exam.   Finally in my fourth year of Optometry I understand why.

I have found that when it comes to binocular vision disorders or what Griffin & Grisham in “Binocular Anomalies: Diagnosis and Vision Therapy” describe as “Visual Efficiency Syndromes” the patient’s chief complaint can almost always direct you to the diagnosis before you even touch your occluder, phoropter or retinoscope.

Here is a common list of complaints/symptoms and possible causes:

1)   Asthenopia: typically defined as ocular discomfort or fatigue.  This condition is often difficult to discern from general fatigue caused by some sort of systemic issue, but you want to rule out an ocular cause that can be contributing to your patient’s discomfort.

2)   Headaches:  If your patient localizes headache pain on their forehead, around their eyes or even in the area of the occipital lobe it may be related to some sort of dysfunction in the accommodative system, binocular system or a combination of the two.  They will often describe their headache as dull and of moderate pain.

3)   Intermittent blur:  This one can occur from an accommodative insufficiency or accommodative infacility.  To discern the two, ask further into when the blur occurs.  If they say they notice distance blur after they are doing a lot of reading and then again if they are copying from the board and then look down- it is most likely more an infacility issue, where they suffer from the inability to quickly adapt to different accommodative demands.  If they describe the blur as blur at near while reading, it is most likely an accommodative insufficiency where they are unable to maintain a high accommodative demand for a long time. 

4)   Diplopia: If they report this it is almost always some sort of vergence dysfunction (most commonly a convergence insufficiency).  You should follow-up asking if it is horizontal, vertical or a combination of the two.  I also recommend some follow-up questions including asking if the child closes one eye to read, turns his head when he reads (a big schnoz can act as an efficient occluder), or if they have any difficulty copying from the board. 

5)   Loss of place/ skipping words/ re-reading:  These are classic signs of an oculomotor dysfunction, a condition that you do not want to miss.  This issue can take a tremendous toll on a child’s learning.   You can identify the child’s ability to make gross saccades and pursuits as well as testing reading eye movements with the King Devick, DEM or Visa-graph to solidify your diagnosis.

I should mention that many kids do not complain.  For this reason I ask every parent if the child is having any difficulty in school.  I follow up this question with asking if the child has made any specific adaptations to indicate some type of visual dysfunction.  Some of these questions include: “do you notice your child getting close to the paper, do they move their head while they read, do they need to follow-along with their finger to read, do they complain of headaches, or avoid doing any near work.”  I will even ask the kids what they are seeing or why they ‘don’t like to read.’  You’ll be amazed at what things you can be revealed when you ask the right questions.

I believe as an Optometrist you have a professional duty to identify binocular/accommodative disorders and either treat or refer appropriately.  Listen to your patients… they are telling you everything you need to know.


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