Comparison of binocular vision indices in Parkinson's disease patients vs age-sex-matched healthy controls.

To assess eye movements and binocular function in 14-year-olds with very low birthweight (VLBW: birthweight </= 1500 g) and 14-year-olds born at term but small for gestational age (SGA: birthweight < 10th percentile) in a population-based study. Ophthalmological examinations including measurements of heterophoria/tropia, near point of convergence, accommodative amplitude, stereopsis, nystagmus, saccades and smooth pursuit were performed in 51 adolescents with VLBW, 58 adolescents born SGA and in a control group consisting of 75 subjects of the same age. Latent or manifest strabismus, poor stereopsis, poor convergence and nystagmus were all more frequent in the VLBW group than in the control group. The VLBW group did not differ from the control group regarding accommodative amplitude or saccades and smooth pursuit. The SGA population did not differ from the control group in the measured variables. Premature birth with VLBW affects binocular visual functions negatively in adolescence, whereas birth small for date at term does not appear to be a risk factor for impaired eye movements and binocular function.

Objective To investigate the characteristics of the objective sleep disturbances in Parkinson’s disease (PD) and the factors related to it. Methods One hundred and one PD patients and 90 age- and sex- matched controls underwent a video-polysomnography. The sleep parameters and its related factors in two groups were analyzed. Results Sleep latency was not statistically different in comparing two groups. PD patients had a higher percentage of non-rapid eye movement（non-REM）sleep stage 1 and a lower percentage of non-REM sleep stage 2 compared with controls（27.9±17.8 vs 21.2±11.7，t=3.034, P=0.003；47.8±17.4 vs 54.7±12.9，t=-3.043, P=0.003）. Reduced sleep efficiency, decreased the proportion of slow wave sleep and REM sleep, increased awake time and longer REM sleep latency occurred in PD patients. There were no significant differences of these above parameters. Some sleep parameters in PD patients were correlated with advancing age, the severity of PD, and the degree of depression. The index of periodic leg movements in sleep (PLMSI) of 41 PD patients (40.6%) was more than 15. These PD patients didn’t complain corresponding symptoms about their legs. The PLMSI in PD patients were significantly higher than the controls. PLMSI increased with aging in the PD group(r=0.261，P<0.01). PD patients didn’t suffer significantly lower apnea- hypopnea index and oxygen desaturation index. The lowest SPO2(L-SPO2)increased in the PD group. REM sleep without atonia occurred in 83 patients (82.2%)with PD．Thirty-eight patients (37.6%) were diagnosed with REM sleep behavior disorder (RBD). The incidences of REM without atonia and RBD in the PD group were significantly higher than in the controls（0 and 8 patients (8.9%), χ2=42.271，102.480; both P<0.01). Conclusions The sleep parameters in PD patients are changed．For PD patients, there is no difficulty in falling asleep. The PD patients also have sleep structure disorder and difficulty in maintaining sleep. The sleep parameters are correlated with advancing age, the severity of PD, and the degree of depression in PD. PLMS don’t lead to sleep disturbances in PD patients. The blood oxygen saturation don’t decrease severely when PD patients suffer apnea or hypopnea. RBD occur more frequently in PD patients.

ObjectsAbnormal blood pressure (BP) regulation is a feature of autonomic dysfunction in Parkinson's disease (PD) patients. The present study was to analyze the BP alterations by 24‐h ambulatory BP monitoring in PD patients with different disease stages and subtypes.Methods32 consecutive patients PD patients and 43 control patients in our hospital from 2017 to 2020 were included. The circadian BP rhythm was divided into three types according to the 24‐h ambulatory BP monitoring. Dipping was defined as an average systolic BP (SBP) reduction during night‐time of 10%–19%. Reverse dipping was defined as an average increase in night‐time SBP values. The differences of the circadian BP rhythm and BP variability (BPV) were analyzed between PD group and the control group, the early PD group and the advanced PD group, as well as the tremor‐dominant group and the nontremor‐dominant group.ResultsThere was statistical difference in circadian BP rhythm between PD group and control group (p < .05). There were statistical differences in circadian BP rhythm between the early PD group and the advanced PD group (p < .05). The mean values of night‐time SBP and diastolic BP (DBP) in the advanced PD group were higher than those in the control group and the early PD group (p < .05). The DBP CV in the advanced PD group was higher than that in the control group and the early PD group (p < .05). There was no significant difference of circadian BP rhythm, mean BP, and BPV between the tremor‐dominant and the nontremor‐dominant PD group after matching the disease duration.ConclusionsReverse dipping was more common in PD patients in this study, especially in the advanced PD patients. 24‐h ambulatory BP monitoring is an important method to evaluate the BP alterations in PD patients. Clinicians should be alert to reverse dipping in PD patients and intervene to prevent serious clinical events.

To investigate the relevance of ABCA1 R219K polymorphisms and serum ABCA1 protein concentration to Parkinson’s disease (PD) pathogenesis and classification in Chinese population. Between June 2013 to January 2014, 108 patients diagnosed with PD at Department of Neurology, Tangshan People’s Hospital, Tangshan were enrolled in the PD group, and 123 healthy individuals, from Health Screening Center of the same hospital, with matched age, gender, and education were enrolled in the control group. Polymerase chain reaction–restriction fragment length polymorphism method was used to detect ABCA1 R219K polymorphisms and enzyme-linked immunosorbent assay used to measure serum ABCA1 concentrations. Frequencies of R/K and K/K genotypes, and K allele of ABCA1 R219K polymorphisms were significantly lower in the PD group than the control group (all P < 0.05). Significant differences existed in distributions of genotype frequencies, including R/R, R/K and K/K, between PD and control group of each classification (all P < 0.05). ABCA1 concentrations were significantly different in the PD and control group (P < 0.05); also ABCA1 concentrations were very different among PD patients with different genotypes (all P < 0.05). Serum concentrations of ABCA1were significantly different among PD patients in different classifications (all P < 0.05), suggesting the negative correlation between ABCA1 serum concentration and PD classification (r = −0.776, P < 0.05). And serum concentrations of ABCA1 showed obvious differences among cases with three different genotypes in each classification (all P < 0.05). ABCA1 R219K polymorphisms and serum concentration were associated with pathogenesis and classification of PD, and K allele may be a protective genetic factor.

Objective To observe the macular retinal thickness and volume in patients with different degrees of Parkinson's disease (PD). Methods Thirty eyes of 30 patients with primary PD and 20 eyes of 20 healthy subjects (control group) in Xuanwu Hospital of Capital Medical University from October 2016 to October 2017 were enrolled in this study. There were 17 males and 13 females, with the mean age of 63.2±6.4 years and disease course of 3.9±2.4 years. The patients were divided into mild to moderate PD group (15 eyes of 15 patients) and severe PD group (15 eyes of 15 patients). The macular area was automatically divided into 3 concentric circles by software, which were foveal area with a diameter of 1 mm (inner ring), middle ring of 1 to 3 mm, and outer ring of 3 to 6 mm. The middle and outer ring were divided into 4 quadrants by 2 radiations, respectively. The changes of retinal thickness and macular volume of the macular center and its surrounding quadrants were analyzed. SPSS 16.0 software was used for statistical analysis. One-way ANOVA were used to analyze all data. Results Compared with the control group, the retinal thickness and volume in macular center and each quadrant of the mild to moderate PD group and severe PD group were reduced. Compared with the mild to moderate PD group, the retinal thickness and volume in macular center and each quadrant of the severe PD group were reduced. The differences of retinal thickness and macular volume among 3 groups were significant(F=5.794, 5.221, 5.586, 5.302, 5.926, 5.319, 5.404, 5.261, 5.603; P=0.001, 0.007, 0.003, 0.005, 0.000, 0.004,0.004, 0.006, 0.002). In inner ring of the mild to moderate PD group and the severe PD group, the retinal thickness and macular volume in the upper and the nasal were the largest, the inferior was followed, and the temporal was the smallest. In outer ring of the mild to moderate PD group and the severe PD group, the retinal thickness and macular volume in the nasal was the largest, the upper was the second, the temporal and the inferior were the smallest. Conclusions The retinal thickness and volume of the macular central fovea and its surrounding areas in PD patients are significantly thinner than that in the healthy subjects. And with the increase of the severity of PD, the macular structure changes obviously, showing macular center and its surrounding macular degeneration thin, macular volume reduced. Key words: Parkinson disease; Macula lutea/pathology; Retina/physiopathology; Tomography, optical coherence/utilization

BACKGROUND: Loss of olfaction is a hallmark of neurodegenerative disorders such as idiopathic Parkinson’s disease (PD) and it may precede the clinical syndrome of PD by many years. Olfactory bulb is probably the earliest site of pathology in PD. This study examines the frequency of unawareness of hyposmia in study cohorts with and without PD and its correlation with cognitive impairment. The objective of this study was to assess olfactory function using the Indian Smell Identification Test (INSIT), which evaluates the unawareness of hyposmia in patients with idiopathic PD. MATERIALS AND METHODS: Olfaction was assessed in 30 PD patients and 30 healthy controls by using INSIT. During this test, the subjects were asked to identify smell from a set of choices and were scored out of 10. The cutoff used for hyposmia was an INSIT score of ≤4. Unawareness was defined as reporting a normal sense of smell in the setting of a low INSIT. Cognitive status was assessed by using Mini Mental State Examination (MMSE) to study the effect of cognitive status on unawareness of hyposmia in PD cases. RESULTS: The mean age for the PD and control groups was 64.3± 10.6 years and 63.9 ± 10.2 years, respectively. Most of the participants were males: 53% and 56% in the PD and control groups, respectively. Out of the 30 patients in each group, 18 patients were unaware of hyposmia in the PD group as compared with 4 patients in the control group. The mean smell identification score using INSIT was 4.13 ± 2.42 in the PD group and 6.86 ± 2.3 in the control group, which was found to be significant with a p value of <0.0001. In the PD group, the mean MMSE score in subjects who were unaware of hyposmia was 27.89, whereas the mean MMSE score in subjects who were aware of smell was 29.25. This was found to be not statistically significant with a p value of 0.1087. CONCLUSION: Unawareness of hyposmia in patients with PD is high as compared with that in the elderly without PD. Under-reporting of hyposmia is seen in patients with PD. There is no increase in the unawareness of hyposmia in patients with PD who exhibit dementia. All these lead to a premise whereby population screening using INSIT could be used for the early detection of PD in those who already harbor the earliest pathology of neurodegeneration.

Objective To investigate MRI appearances of aquaporin(AQP) and its effect in different brain regions of patients with Parkinson's disease(PD). Methods A prospective study was carried out in 33 PD patients(PD group) and 23 gender- and age-matched healthy controls(control group). Clinical data of PD patients were collected.The aquaporin imaging of diffusion-weighted magnetic resonance imaging(MR-DWI) with multiple b-values in different brain regions were performed to detect the apparent diffusion coefficient(AQP-ADC) values of aquaporin.The PD patients were assessed and graded by modified Hoehn-Yahr grading, then the AQP-ADC values of control group, mild PD group, moderate and severe PD group were analyzed using one-way analysis of variance.The correlation analysis was carried out to detect the relationship between AQP-ADC values in different brain regions and Hoehn-Yahr grading of PD patients. Results Compared with control group, mild PD group had significantly higher AQP-ADC values in red nucleus(RN) and globus pallidus(GP) ((0.24±0.04) vs (0.21±0.04), ( 0.21±0.04) vs (0.16±0.04); both P 0.05); and there was also no significant difference in substantianigra(SN), putamen(Pu) and thalamus(THA) among control group, mild PD group and moderate and severe PD group(P>0.05). The correlation analysis showed that there were negative correlations between the AQP-ADC values in RN and GP and Hoehn-Yahr grading(r=-0.479 and -0.395, P 0.05). Conclusion The AQP-ADC values are increased in RN and GP of mild PD patients, and decreased in moderate and severe PD patients, while there is no significant change in SN, Pu and THA of the two groups, suggesting that the expression of AQP in different brain regions may be related to the severity and pathological stage of PD. Key words: Parkinson's disease; Aquaporin; Molecular imaging; Diffusion-weighted magnetic resonance imaging

ABSTRACTPurpose: To determine the prevalence of strabismus and amblyopia, and the distribution of the near point of convergence (NPC), in a population of children aged 4 to 6 years.Methods: In this cross-sectional study, preschoolers in Mashhad were sampled using a random multistage cluster sampling approach. Examinations were done after obtaining parental consent. All participants had measurements of uncorrected visual acuity, corrected visual acuity, and non-cycloplegic refraction, and they had near and far cover tests to determine tropia and phoria.Results: Of the 3765 selected children, 3701 participated in the study. The prevalence of tropia was 1.21% (95% confidence interval [CI]: 0.86–1.57). Near and near/far tropia was observed in 0.83% (95% CI: 0.53–1.12) and 0.39% (95% CI: 0.18–0.59), respectively. Tropia was significantly more prevalent in boys (P=0.005). The most common type of tropia was esotropia, 0.22% (95% CI: 0.07–0.37). Among participants, 63.92% (95% CI: 62.36–65.48) had phoria; prevalence of far, near, and near/far phoria was 0.22% (95% CI: 0.07–0.37), 60.47% (95% CI: 58.88–62.07), and 3.22% (95% CI: 2.65–3.8), respectively. Mean NPC was 5.1 cm (95% CI: 5.05–5.14). NPC increased by 0.08 cm per month of age (P=0.033) and was 0.10 cm higher in boys compared to girls (P=0.027). Based on NPC, 61.58% (95% CI: 59.99–63.17) were symptomatic. The prevalence of amblyopia was 0.41% (95% CI: 0.20–0.61). The type of amblyopia was anisometropic, strabismic, and isoametropic in 75%, 11.1%, and 8.5%, respectively.Conclusion: The prevalence of amblyopia in this study population was not high; however, the prevalence of tropia was average compared to previous studies in Iran. Describing NPC in a 4- to 6-year-old Iranian population for the first time, we found that NPC increased with age in this sample.

P3-078: Prominent reduction in cerebrospinal fluid homovanillic acid and 5-hydroxyindole acetic acid levels in dementia with Lewy bodies

The performance of patients with Parkinson's disease on two reach-to-grasp tasks was compared with that of age-matched control subjects. The aim of the study was to determine whether Parkinson's disease patients have problems coordinating concurrently executed tasks within the same system of effectors in a natural context and whether such problems would be exacerbated by increases in task difficulty. We examined how subjects concurrently executed the transport and grasp components of reach-to-grasp movements in the presence of two types of change in task demands: (i) increases in demands for accurate digit pad placement and (ii) use of two reach-to-grasp tasks, i.e. the standard unimanual task and a bimanual task which increased the control and coordination demands relative to the unimanual task. If Parkinson's disease patients have coordination problems they should demonstrate increased impairment with increasing accuracy demands and in the bimanual task; any such differences should be absent or much smaller in the control group. The Parkinson's disease group showed substantial impairments in all conditions, moving about 30% slower than the control group, with much increased jerking and with signs of difficulty controlling the speed of movement. However, there were no consistent indications that the Parkinson's disease group were differentially impaired on the bimanual task nor that movement deficits increased with increasing accuracy requirements. Grasp and transport components were coordinated similarly by Parkinson's disease and control groups in both reach-to-grasp tasks, and the Parkinson's disease group co-ordinated the two limbs in the bimanual task effectively and in a fashion similar to that of the control group. These results are interpreted to mean that higher levels (effector-independent levels) of motor programming are preserved in Parkinson's disease and that execution of a motor programme need not be compromised by increasing the number of muscle-/joint-level degrees of freedom which are used.

Objective To detect the change of serum cystatine C (cys C) level in Parkinson’s disease (PD) patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) and explore its influencing factors. Methods Fifty-six PD patients with polysomnography examination from July 2011 to December 2013 in the Department of Neurology, the Second Affiliated Hospital of Soochow University were collected. Eighteen healthy controls who took the polysomnography examination during the same period were included. According to the apnea-hypopnea index (AHI), PD patients were further divided into two groups: PD with OSAHS group (n=26), and PD group (n=30). The general conditions, movement function, biochemistry parameters, and sleep parameters were assessed. Statistical analysis was performed using SPSS ver 17.0 software. Results The mean serum levels of cys C in PD with OSAHS group, PD group and control group were (1.05±0.17) mg/L, (0.96±0.12) mg/L and (0.84±0.20) mg/L, respectively. Statistical analysis showed that there was significant difference in the three groups(F=9.184，P 0.05). Multivariate analysis showed that creatinine levels (B=0.007，P=0.005), AHI (B=0.004，P=0.013) , H-Y stage (B=0.102，P=0.026) may be influencing factors of cys C levels in PD patients (P<0.05). Conclusions Cys C level is elevated in PD patients, especially in PD patients with OSAHS. The degree of hypoxia and severity of PD is related to the level of cys C in PD patients with OSAHS. Key words: Parkinson disease; Sleep apnea, obstructive; Cystatin C

ABSTRACTPurpose: To determine the distribution of near point of convergence (NPC) and its related factors in 6 to 12-year-old children. Methods: In a cross-sectional study in 2015, the urban and rural children of Shahroud, north of Iran, were sampled. All rural schoolchildren were invited to the study, and in the urban area, we conducted random cluster sampling. Examinations included measurement of uncorrected and corrected visual acuity, manifest, subjective, and cycloplegic refraction. NPC and near point of accommodation (NPA) were measured with the best optical correction. Results: Of the 6624 sampled schoolchildren, 5620 participated in the study, and after applying the exclusion criteria, the final analysis was conducted on data from 5444 students; their mean age was 9.24 ± 1.71 years (6–12 years) and 53.6% (n = 2918) of them were male. Mean NPC was 8.08 cm [95% confidence interval (CI): 7.96–8.19]; 8.07 cm (95% CI: 7.92–8.22) in males and 8.08 cm (95% CI: 7.91–8.25) in females (p = 0.954). NPC significantly recessed with age (p < 0.001). Mean NPC in emmetropic, myopic, and hyperopic children were 8.13, 7.04, and 8.23 cm, respectively (p < 0.001). The multiple linear regression model revealed significant associations for NPC with age (coefficient = 0.10, 0.95% CI: 0.05–0.15, p < 0.001), spherical equivalent refraction (coefficient = 0.17, 95% CI: 0.10–0.24, p < 0.001), and NPA (coefficient = 0.83, 0.95% CI: 0.76–0.90, p < 0.001). Conclusion: Mean NPC in 6–12-year-old Iranian children was 8.08 cm, which is worse than values reported in previous studies. Mean NPC showed a slight recession with age. Myopic schoolchildren had the least remote and hyperopes had the most remote NPC values. More remote values of NPA were associated with receded NPC.

Neurological conditions such as Parkinson's disease are commonly accepted as a risk factor for an increased likelihood of undergoing revision surgery or death after THA. However, the available evidence for an association between Parkinson's disease and serious complications or poorer patient-reported outcomes after THA is limited and contradictory. (1) Do patients with a preoperative diagnosis of Parkinson's disease have an increased risk of death after elective THA compared with a matched control group of patients? (2) After matching for patient- and surgery-related factors, do revision rates differ between the patients with Parkinson's disease and the matched control group? (3) Are there any differences in patient-reported outcome measures for patients with Parkinson's disease compared with the matched control group? Data were derived from a merged database with information from the Swedish Hip Arthroplasty Register and administrative health databases. We identified all patients with Parkinson's disease who underwent THA for primary osteoarthritis between January 1, 1999 and December 31, 2012 (n = 490 after exclusion criteria applied). A control group was generated through exact one-to-one matching for age, sex, Charlson comorbidity index, surgical approach, and fixation method. Risk of death and revision were compared between the groups using Kaplan-Meier and log-rank testing. Patient-reported outcome measures (PROMs), routinely recorded as EQ-5D, EQ VAS, and pain VAS, were measured at the preoperative visit and at 1-year postoperatively; mean absolute values for PROM scores and change in scores over time were compared between the two groups. The risk of death did not differ at 90 days (control group risk = 0.61%; 95% CI = 0.00-1.3; Parkinson's disease group risk = 0.62%; 95% CI = 0.00-1.31; p = 0.998) or 1 year (control group = 2.11%; 95% CI = 0.81-3.39; Parkinson's disease group = 2.56%, 95% CI = 1.12-3.97; p = 0.670). At 9 years, the risk of death was increased for patients with Parkinson's disease (control group = 28.05%; 95% CI = 22.29-33.38; Parkinson's disease group = 54.35%; 95% CI = 46.72-60.88; p < 0.001). The risk of revision did not differ at 90 days (control group = 0.41%; 95% CI = 0.00-0.98; Parkinson's disease group = 1.03%; 95% CI = 0.13-1.92; p = 0.256). At 1 year, the risk of revision was higher for patients with Parkinson's disease (control group = 0.41%; 95% CI = 0.00-0.98; Parkinson's disease group = 2.10%; 95% CIs = 0.80-3.38; p = 0.021). This difference was more pronounced at 9 years (control group = 1.75%; 95% CI = 0.11-3.36; Parkinson's disease group = 5.44%; 95% CI = 2.89-7.91; p = 0.001) when using the Kaplan-Meier method. There was no difference between the control and Parkinson's disease groups for level of pain relief at 1 year postoperatively (mean reduction in pain VAS score for control group = 48.85, SD = 20.46; Parkinson's disease group = 47.18, SD = 23.96; p = 0.510). Mean change in scores for quality of life and overall health from preoperative measures to 1 year postoperatively were smaller for patients in the Parkinson's disease group compared with controls (mean change in EQ-5D scores for control group = 0.42, SD = 0.32; Parkinson's disease group = 0.30, SD = 0.37; p 0.003; mean change in EQ VAS scores for control group = 20.94, SD = 23.63; Parkinson's disease = 15.04, SD = 23.00; p = 0.027). Parkinson's disease is associated with an increased revision risk but not with short-term mortality rates relevant to assessing risk versus benefit before undergoing THR. The traditional reluctance to perform THR in patients with Parkinson's disease may be too conservative given that the higher long-term risk of death is more likely due to the progressive neurological disorder and not THR itself, and patients with Parkinson's disease report comparable outcomes to controls. Further research on outcomes in THR for patients with other neurological conditions is needed to better address the broader assumptions underlying this traditional teaching.Level of Evidence Level III, therapeutic study.

Objectives To observe the characteristics of sacral reflex and sympathetic skin reflex in patients with Parkinson's disease (PD) and multiple system atrophy P-type (MSA-P) and to analyze their value as a differential diagnostic method. Methods The data of 30 healthy people, 58 PD patients, and 52 MSA-P patients from the First Affiliated Hospital of Wenzhou Medical University were collected. Electrophysiological bulbocavernosus reflex (BCR) and sympathetic skin response (SSR) were evaluated using the Keypoint EMG/EP system. The latency period, amplitude, and extraction rate of BCR and SSR were compared between the control, PD, and MSA-P groups. Results The incidence of the related autonomic damage in the PD group was lower than that of the MSA-P group. For BCR, the latency period was shorter and the amplitude and elicitation rates were lower in the PD group than in the MSA-P group. For SSR, the latency period was longer in the MSA-P and PD groups than in the control group, but the difference was not statistically significant. Conclusion SSR cannot be used to assess autonomic nerve function. PD patients can have clinical symptoms similar to those of MSA-P patients, but the incidence is lower. Both MSA-P and PD patients have a damage to the BCR arc, but the MSA-P patients have a more severe damage.

PurposeThe aim was to determine the distribution of the near point of convergence (NPC) and its association with age, gender and refractive errors through a population‐based study.MethodsIn this cross‐sectional study, samples were randomly selected from the population of Mashhad city in the northeast of Iran through stratified cluster sampling. In each of the 120 randomly selected clusters, 10 households were systematically chosen. Examinations included visual acuity testing, refractive and binocular vision examination. NPC was measured using a 6/12 single target on a Gulden fixation stick. Positive and negative fusional vergences were measured by the step method at far and near fixation distances.ResultsOf the 4,453 invitees, 3,132 people participated (response rate of 70.4 per cent) and after applying the exclusion criteria, analysis was conducted on data from 2,433 individuals whose mean age was 31.2 ± 15.1 years (range: 10 to 86 years). Mean NPC was 8.59 ± 4.82 cm (range: 2 to 40 cm) in the total sample, 6.95 ± 3.87 cm in the 10–19 years age group and 13.06 ± 5.2 cm in those over 70 years. The relationships of NPC with the variables ages, gender and refractive errors (spherical equivalent) was assessed in a multiple linear regression model. Based on this model, older age (p < 0.001, coefficient = 0.106), male gender (p = 0.002, coefficient = 0.608) maintained a significant correlation with NPC, while the association with refractive error was no longer significant (p = 0.109, coefficient = 0.128) after adjusting for age and gender.ConclusionThis is the first population‐based study to examine the normal ranges of NPC and also the first to describe normal values in a presbyopic population. The results of this study indicate an age‐related change in NPC. These changes should be noted in the interpretation of tests for the diagnosis and treatment of problems with binocular vision.