Is my residency over?

[Toadkiller Dog]

Allright, so, 3 months into ophtho residency, I have discovered an important critical fact: I cannot use the indirect without getting diplopia.

Here's the deal: I put the headset on, adjust it to my IPD, and hold my thumb out. Only one thumb, good. Now, I hold out my 20D lens, and stick my thumb or a pencil point under it. Only one pencil point, upside down and backwards. Good.

Now I hold the lens in front of my patient's eye, and adjust. Nice, clear view of the retina (in most patients). But with 2 optic nerve heads, 2 sets of vasculature, etc. I have to close one eye to make out what I'm looking at. I've tried adjusting the headset till kingdom come, and I get the same results.

Incidentally, I can use the slit lamp/78/90 with good stereopsis.

I shared this with one of my chiefs that I trust, and he did a quick cover/uncover on me, and discovered that I had exophoria at near (i.e, convergence insufficiency). It's pretty mild, and I'm not entirely convinced it explains my problem, although it does seem likely.

This is very frustrating. I'm just getting to the point where I'm actually enjoying residency (a little), but I'm not sure how to deal with this. My chief told me not to tell anyone, especially the attendings, or I would get a reputation or possibly even fired. Encouraging, eh?

Thoughts?

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[PBEA]

Allright, so, 3 months into ophtho residency, I have discovered an important critical fact: I cannot use the indirect without getting diplopia.

Here's the deal: I put the headset on, adjust it to my IPD, and hold my thumb out. Only one thumb, good. Now, I hold out my 20D lens, and stick my thumb or a pencil point under it. Only one pencil point, upside down and backwards. Good.

Now I hold the lens in front of my patient's eye, and adjust. Nice, clear view of the retina (in most patients). But with 2 optic nerve heads, 2 sets of vasculature, etc. I have to close one eye to make out what I'm looking at. I've tried adjusting the headset till kingdom come, and I get the same results.

Incidentally, I can use the slit lamp/78/90 with good stereopsis.

I shared this with one of my chiefs that I trust, and he did a quick cover/uncover on me, and discovered that I had exophoria at near (i.e, convergence insufficiency). It's pretty mild, and I'm not entirely convinced it explains my problem, although it does seem likely.

This is very frustrating. I'm just getting to the point where I'm actually enjoying residency (a little), but I'm not sure how to deal with this. My chief told me not to tell anyone, especially the attendings, or I would get a reputation or possibly even fired. Encouraging, eh?

Thoughts?

Cool, that actually sounds like a realife binocular vision issue! Although I'm betting that your competing for some other reason. I would double check my BIO measurements first. If your sure you cant resolve a single image, then guess what? Try harder!! I mean it, force your accomodative system to focus, damn it . IF its really CI then your either borderline and might/should be able to force a single image, OR, you suppress at some distance from your nearpoint. That is of course unless its recently acquired/noticed, for which a patch , or vision therapy may help. That's fu about your residency, but from here I'd say you can overcome this no problem, just focus

 

[PBEA]

Oh, I forgot to mention the ever present ubiquitous prism. This is a virtually fool proof option for the mild-moderate CI. Provided of course that you do indeed have CI, and that it is causing your diplopia.

 

[UABopt]

Allright, so, 3 months into ophtho residency, I have discovered an important critical fact: I cannot use the indirect without getting diplopia.

Here's the deal: I put the headset on, adjust it to my IPD, and hold my thumb out. Only one thumb, good. Now, I hold out my 20D lens, and stick my thumb or a pencil point under it. Only one pencil point, upside down and backwards. Good.

Now I hold the lens in front of my patient's eye, and adjust. Nice, clear view of the retina (in most patients). But with 2 optic nerve heads, 2 sets of vasculature, etc. I have to close one eye to make out what I'm looking at. I've tried adjusting the headset till kingdom come, and I get the same results.

Incidentally, I can use the slit lamp/78/90 with good stereopsis.

I shared this with one of my chiefs that I trust, and he did a quick cover/uncover on me, and discovered that I had exophoria at near (i.e, convergence insufficiency). It's pretty mild, and I'm not entirely convinced it explains my problem, although it does seem likely.

This is very frustrating. I'm just getting to the point where I'm actually enjoying residency (a little), but I'm not sure how to deal with this. My chief told me not to tell anyone, especially the attendings, or I would get a reputation or possibly even fired. Encouraging, eh?

Thoughts?

It is not uncommon for people to trope on these various instruments. This tends to be more of a problem when viewing relatively unfamiliar objects. I for one used to trope eso in front of the slit lamp. This is quite common as proximal convergence usually kicks in when you have something put close to your eyes, yet the image remains optically at a distant location so you see two. Keep working on it and it should get better as you become more and more familiar with the images that you are seeing. As others have said a full BV workup (including a cycloplegic refraction if indicated) would not hurt in your case, certainly a quick cover test is not going to definitively diagnose this BV problem. Who knows what your eyes are doing behind the BIO, I would venture to guess they are more likely ESO than EXO simply because of the likelihood of proximal convergence but you never know. The books say… for CI do VT (which I suppose could help but for this specific case would really kind of be a pain) but in your case I would just get a pair of trial frames and play with some prisms to see if you cannot fix it. Don't try to over do it. A few prism diopters BI should do it if it is indeed CI…. If however you have an ET you would need BI, really you won't know until you try. There is no test that you can do that is going to simulate the exact conditions of BIO so really I think trial and error would work best. If you find a combination that works for you, try it out for a little while, and then you can have a pair of "BIO glasses" made up.

For several months I used to tape a prism up in front of the slit lamp, but over time it just got better and then suddenly I was able to fuse without the help of prism. I do know a few people though that continue to use "slit lamp specs." I suppose you could also replace the +2.00D lenses in the BIO with prism though that would probably be more difficult than just having some specs made up and wearing them under the BIO.

One last thing... make sure that you are not making the PD too wide or too narrow as when you are looking through +2.00 you can create a BI or BO effect. Also (assuming you are not a presbyope) before you do anything else try to remove the +2.00 lenses. That really can help a whole lot for some people, on the other hand if you are troping eso it will make matters worse.

Good luck!!

 

[Caffeinated]

I used to be diplopic when I first used an indirect. Because the indirect is unfamiliar, and does not have a lot of peripheral cues to fusion, then it is easy to manifest your otherwise latent exo at near. Here are a few suggestions for you:

1. As mentioned in a previous post, take the +2.00 lenses out of the indirect and replace with the planos (if you can find them). This may help, but maybe not. CI by definition has a low AcA ratio, so forcing yourself to exert the extra +2.00 of accommodation by taking out the lenses in the indirect may not buy you enough accommodative convergence to get you fused.

2. Do you wear glasses or contacts? If you do not wear glasses, you may consider having a pair of glasses (even planos can work) to wear with the indirect. Sometimes having the frame in your peripheral vision is enough to keep your fusion.

3. As you start to become diplopic, try wagging your finger in front of one eye or the other, or at least off to the side. Sometimes this dynamic stimulus is enough to trigger fusion. Once you get it fused, you will get even better at it over time.

4. Try a Brock string exercise (a string with some beads on it). Hold the tip of the string on the end of your nose, and look at a bead at some distance from your nose (start with 40-50 cm). You should see a diplopic string in front of and behind the bead. If you are truly CI, you may start to perceive the intersection of the strings behind the bead due to your normal convergence lag. Try to get good at holding the intersection through the bead. If you don't see the diplopic string, you are suppressing. Try the finger wagging to bring it back. After that, try to keep the intersection of the string on the bead as you move it toward you and away from you. Then get several beads and try jumping back and forth up and down the string. It's a goofy exercise, but some people get pretty quick results. Like I said before, once you figure out how to make yourself fuse, it gets easier every time.

5. I would NOT recommend patching. This might further break down any convergence ability you had before, and make things worse.

6. Continue practicing indirect. Find a volunteer who is willing to let you practice on them after hours. Maybe even have a resident watch you to make sure it's not a technique issue.

Best of luck to you.

 

[Toadkiller Dog]

Thanks for the input. I've tried some of the above exercises, but to little avail. I'll keep practicing, though.

Until then, it's one-eyed Toadkiller for me!

 

[Mirror Form]

Allright, so, 3 months into ophtho residency, I have discovered an important critical fact: I cannot use the indirect without getting diplopia.

One pgy-3 at my program had a similar issue using the indirect during his pgy2 year. He actually got somewhat good at doing the depressed exam from the slit lamp!

As far as CI goes, you might want to talk to a pediatric ophthalmologist. I may be thinking of something else, but there may be some exercises you can do that will make you less likely to trop (eg, focusing on a pencil a few inches from your face 20 times per day).

 

[Retinamark]

I agree with the others above who have mentioned it - try an indirect without the +2.00 lenses. Even now if I use an indirect with the +2's in it, I have to really struggle to fuse.