Vertical Deviations
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Vertical Deviations Hyperphoria is a latent, or hidden, upward deviation of one eye. It is often associated with other conditions like horizontal misalignments or incomitant, or non-equal, muscle deviations. Primary hyperphoria of less than 3 degrees is generally due to slight anatomical differences between the eyes. Symptoms can be relieved through refractive correction, orthoptic treatment with prisms, or in rare cases surgery. Dissociated vertical deviation is a rare anomaly where the covered eye moves upward behind the cover regardless of which eye is covered.
Vertical Deviations
- 2. Hyperphoria Hyperphoria is a latent deviation of one eye upwards In hypophoria the deviation is downwards and as hypophoria of one can be regarded as hyperphoria of the other The term hypophoria is not generally used and the convention is to refer to whichever is the hyperphoric eye.
- 3. RE LE Non-dissociated state cover uncover LE moves up LE moves down Left hyperphoria = Right hypophoria
- 4. RE LE Non-dissociated state cover uncover RE moves up RE moves down Right hyperphoria = Left hypophoria
- 5. Aetiology Hyperphoria is often a secondary condition associated with the following: I) Horizontal heterophoria high degrees of comitant eso- or exophoria are often accompanied by a small vertical component. II) Incomitant deviations paretic conditions involving the elevator or depressor may begin as hyperphoria and later develop into a squint. Congenital incomitant deviations are often associated with vertical deviations but symptoms are usually less severe.
- 6. Aetiology III) Poor fitting spectacles can often introduce vertical prism and can induce a heterophoria. Usually the Px will adapt quite quickly to the presence of this prism and so the hyperphoria may reduce only to reappear when the spectacles are removed are straightened.
- 7. Primary hyperphoria is seldom > 3 generally considered to be due to slight anatomical misalignments of the eyes and/or orbits or muscle insertions. Vertical hyperphoria is not associated with the convergence system in the way horizontal heterophorias are and therefore do not tend to differ between near and distance fixation. Pxs are less tolerant to vertical deviations and decompensation can occur. Aetiology
- 8. Investigation I) Symptoms these can be very marked in hyperphoria, even when the magnitude is low. - frontal headache, diplopia, ocular discomfort or pain There can be a head tilt which helps alleviate the symptoms of diplopia, as does the closure of one eye. II) Motility test should always be undertaken with close observation of the eyes and attention to any reports by the Px of increased regions of diplopia.
- 9. III) Refraction Pay close attention to the binocular balancing of the prescription. An unbalanced correction can often be the cause of hyperphoria. IV) Compensation assessment cover test, TIB test and fixation disparity useful in the assessment of a vertical heterophoria. Investigation
- 10. Management REMOVAL OF THE CAUSE OF DECOMPENSATION II) REFRACTIVE CORRECTION in many cases proper refraction and binocular balancing will alleviate the hyperphoria without any form of treatment necessary. Sometimes the TIB test will reveal a vertical misalignment initially, but this is corrected when binocular balancing is performed. In cases of marked anisometropia where no correction has previously been worn a partial correction of the more hyperopic eye may prevent disturbance by vertical prismatic The correction is reduced in the more hyperopic eye until the vertical phoria is compensated when looking a little above or below the optical centres.
- 11. III) ORTHOPTIC TREATMENT Exercising the vertical fusional reserves does not seem very useful. RELIEVING PRISMS most primary hyperphoria can be relieved by small vertical prisms. The smallest prism that will level the letters in the TIB test or the Mallet Unit may be used to prescribe the smallest prism that alleviates the fixation disparity. It is usual to divide the prism power between the two lenses. Management
- 12. V) REFERRAL incomitant hyperphoria of recent onset should be referred for medical treatment. Where there is a high degree of hyperphoria or there is a congenital incomitancy surgical relief may be considered. Management
- 13. Dissociated Vertical Deviation This is a comparatively rare anomaly (also known as Alternating Sursumduction) and can be mistaken for hyperphoria. It is detected when the eyes are dissociated, the covered eye deviates slowly upwards possibly by as much as 25 . This differs from hyperphoria in whichever eye is covered there is an upward movement behind the cover. When the eye is uncovered the eye moves slowly down again to take up fixation.
- 14. RE LE cover uncover LE moves up LE moves down RE LE RE moves up RE moves down Dissociated Vertical Deviation