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• INTRODUCTION:-

Treatment of heterophoria is indicated mainly in patients with decompensated heterophoria (i.e. symptomatic cases).

• IN ADULTS:- indicated only if the patient is suffering from any symptoms.
• IN CHILDREN:- if the phoria is showing a tendency to decompensate into a manifest deviation, whether symptoms are present or not.

• FOUR TYPES OF TREATMENT ARE THERE FOR TREATING HETEROPHORIA:-

OPTICAL CORRECTION:-

1. Optical correction may eliminate the phoria in some patients.
2. Prescription guidelines for glasses:-
3. Differences in refractive error between two eyes should be eliminated.
4. Both the eyes may be under-correct by an equal amount of spherical plus power in exophoria.
5. The optimum spherical plus correction gives the best visual acuity in esophoria.
6. Bifocal glass, for near vision with the patient having esophoria of convergence excess type.
7. Optical correction by decentred to achieve the prismatic effect, relieving the stress on vertical vergence in hyperophoria.
8. In cyclophoria, correction of astigmatic refractive error.

ORTHOPTIC TREATMENT (VISION THERAPY):-

1. It is indicated in patients with heterophoria without refractive error and in those where heterophoria and /or symptoms are not corrected by glasses.
2. The aim is to improve fusional reserve so that the foveal single vision can be maintained without effort.

ORTHOPTIC EXERCISE FOR ESOPHORIA:- (DIVERGENCE EXERCISE WITH PRISM)

1. Base-In prism in front of one eye while the patient fixates on an object where the esophoria is maximum.
2. Trained to maintain single vision by relaxing the convergence (for a few minutes at each week visit).

DIVERGENCE EXERCISE ON SYNOPOPHORE:-

1. Using stereopsis slides provides a strong stimulus to fusion.
2. Trained to maintain a single vision by relaxing convergence (5minutes at each week visit).

PHYSIOLOGICAL DIPLOPIA EXERCISE:-

1. Using a pencil or stereogram in the crossed position.
2. The patient should fixate on the distance objects, and pencil/stereogram card held at 25cm in front of the eyes.
3. The patient perceives four pictures.
4. Trained to fuse two central pictures, in which patient perceives three pictures.
5. Here pt. is converging for the distance target while accommodation for near.

OTHER METHODS FOR ORTHOPTIC EXERCISE FOR ESOPHORIA:-

1. Exercise using diploscope.
2. Exercise using Remy separator.
3. Reading bar exercise.

ORTHOPTIC EXERCISE FOR EXOPHORIA:- (CONVERGENCE EXERCISE WITH PRISM)

• Base-Out prism in front of one eye while the patient fixates an object where the exophoria is maximum.
• Trained to maintain single vision by relaxing the divergence (for a few minutes at each week’s visit).

CONVERGENCE EXERCISE ON SYNOPOPHORE:-

• Using stereopsis slides which provides a strong stimulus to fusion.
• Trained to maintain a single vision by relaxing divergence (5minutes at each week’s visit).

PHYSIOLOGICAL DIPLOPIA EXERCISE:-(IN UNCROSSED POSITION)

• Use a pencil or stereogram in the uncrossed position.
• The patient should hold the stereogram card at arm’s length in front of the eyes and a pencil (fixating point) is placed between the eyes and the card.
• While looking at the pencil, pt. will notice diplopia (uncrossed) of the card (i.e. four pictures).
• Trained to fuse two central pictures, in which patient perceives three pictures.
• Here pt. is converging for the fixating object while accommodation for distance.

PRESCRIPTION OF PRISM IN GLASSES:-

• It may be tried in selected cases of hyperphoria and in troublesome cases of esophoria and exophoria.
• Prism is prescribed with an apex toward the direction of phoria to correct only half or at the most two-thirds of heterophoria.

ROLE OF MIOTIC DRUGS:-

• Treatment of choice in near esophoria due to high AC/A ratio.
• Miotics facilitate accommodation so that less than normal innervations are necessary to obtain a given accommodation response and there occurs less accommodative convergence.

SURGICAL TREATMENT:-

• Indication:- surgery becomes necessary only when symptoms cannot be relieved by another method like optical correction, orthoptic exercise, or using miotic.

Aim of the surgical management is to strengthen the weak muscle or weaken the strong muscle.