Mallett Unit Research Articles

Agreement of Fixation Disparity Curve between Two Different Instruments.

Fixation disparity tests with various characteristics of fusional stimulus are very important for assessment of decompensated heterophoria. The results suggest that there was no reasonable agreement between the fixation disparity curve's parameters of the modified near Mallett unit and the Sheedy disparometer. The purpose of this study was to determine the agreement of the fixation disparity curve parameters between the modified near Mallett unit and the Sheedy disparometer in patients with decompensated near heterophoria. A total of 147 young adults (mean age, 22.7 ± 4.8 years) participated in this cross-sectional study. After applying the exclusion criteria, the statistical analysis was done on the data of 134 individuals. All participants underwent preliminary optometric examinations including the measurement of uncorrected and best-corrected visual acuity, objective and subjective refraction, and unilateral and alternating cover tests. The fixation disparity was evaluated using the modified near Mallett unit and the Sheedy disparometer at 40 cm, and forced-vergence fixation disparity curves were generated. There were statistically significant differences in the fixation disparity curve parameters (except the center of symmetry) between the two devices. The median fixation disparity measured by the Sheedy disparometer was more positive compared with the modified near Mallett unit (toward more esodisparity or less exodisparity). The median associated phoria measured by the Sheedy disparometer was more positive compared with the Mallett unit. Also, the slope of the curve obtained by the Mallett unit was steeper. The wide limits of agreement indicated the poor agreement of all fixation disparity curve parameters between the two instruments.

Evaluation of the presence of a central fusion lock effect on fixation disparity curve parameters in symptomatic and asymptomatic subjects

ABSTRACT Clinical relevance: Several parameters are likely to affect the magnitude of fixation disparity (FD) and FD curve characteristics. Presence of a central fusion lock may have an important effect on clinical testing of FD and interpretation of its results. Background: The aim of this study was to evaluate FD curve parameters using the modified near Mallett unit (with a central fusion lock) and the Sheedy disparometer (without a central fusion lock) in symptomatic and asymptomatic subjects. Methods: This cross-sectional study was conducted in 147 patients with a mean age of 22.5 years who presented to the optometry clinic of Paramedical College of Mashhad University of Medical Sciences. The symptoms were recorded in a questionnaire for each patient. FD was measured using the modified near Mallett unit and Sheedy disparometer and FD curves were generated using the AutoCAD 2005 software. Results: There was a significant difference in the FD, associated phoria, and slope measurements between the two devices (all p values < 0.05). Significant difference was found in the mean FD between symptomatic and asymptomatic subjects using the modified near Mallett unit (p < 0.0001) and Sheey disparometer (p = 0.007). In symptomatic subjects, the mean slope was steeper for the modified near Mallett unit compared to the Sheedy disparometer (p = 0.001). Although the mean centre of symmetry was more negative in the modified near Mallett unit versus the Sheedy disparometer, the difference between the instruments was not significant in symptomatic (p = 0.477) and asymptomatic (p = 0.257) participants. Conclusion: There are differences in the FD curve parameters between the modified near Mallett unit and Sheedy disparometer. Slope is a proper criterion for differentiating asymptomatic subjects from symptomatic individuals. The modified near Mallett unit is a more precise tool for assessment of non-compensated heterophoria compared to the Sheedy disparometer.

Is reading rate in digital eyestrain influenced by binocular and accommodative anomalies?

IntroductionSymptoms experienced when using digital devices are known as digital eyestrain (DES) or computer vision syndrome. They can be categorised as either external (associated with dry eye) or internal (related to refractive, accommodative or binocular vision anomalies). In a large cohort of adults with DES, we investigate the prevalence of binocular and accommodative anomalies, contrasting different diagnostic approaches, to evaluate potential mechanisms for the benefit from +0.75D addition lens that has been previously reported. MethodsParticipants (20−40y) were selected using the Computer Vision Syndrome Questionnaire (CVS-Q) tool as suffering with DES. A comprehensive eye examination was given to each participant, and this paper concentrates on “internal factors”, detected with a refraction and comprehensive testing of binocular and accommodative functions. The effects of low-powered addition lenses (+0.50D, +0.75D, +1.25D; and plano controls) were assessed by double-masked testing with the Wilkins Rate of Reading Test (WRRT) and by subjective preference. ResultsAs previously reported, most participants showed a subjective preference for one of the three convex lenses we used, with +0.75D chosen most frequently. Performance at the WRRT was significantly improved with +0.50D and +0.75D, but not +1.25D. Using a variety of diagnostic criteria, there were no strong associations between WRRT results or CVS-Q scores and any binocular or accommodation functions. The one finding of significance is that a disproportionate number of participants who benefited from adds had an eso-fixation disparity on the near Mallett unit, although this only affected 5% of the population. ConclusionsDES is a collection of diverse symptoms that have a multifactorial aetiology. In the sample described here, binocular and accommodative anomalies do not seem to be a major cause of DES. Nevertheless, in view of the multifactorial aetiology it is recommended that patients with the symptoms of DES are assessed with a comprehensive eye examination. Patients with an esophoric fixation disparity on the near Mallett unit are particularly likely to benefit from near additions.

Clinical Characteristics of Patients Presenting with Headache at Binocular Vision Clinic: A Hospital Based Study

Purpose: To assess the clinical characteristics of patients presenting with headache at binocular vision clinic.Place and Duration of Study: Al-Neelain eye hospital, Sudan, from February to October 2018.Study Design: Cross-sectional study.Material and Methods: One hundred fifty patients with history of headache were included in study. Dissociated heterophoria was measured using Maddox Wing and Maddox Rod. Associated heterophoria was assessed by the Mallett unit fixation disparity and fusional vergence was measured using a prism bar. The relationship between measures was determined using the chi-squared analysis. For all statistical determinations, significance levels were set at p &lt; 0.05.Results: Mean age was 25 ± 3.5 years. Femalesconstituted 78% and headache was significantly associated with females (P &lt; 0.0001). Majority of patients (82%)presented with exophoria (mean = 4.74 ± 0.75 Δ Base-In) at near fixation, 10.7% were orthophoric and7.34percentage were esophoric (mean = 3.24 ± 0.5 Δ Base-Out). The association between near heterophoria andheadache was statically significant (χ2 = 7.426; p = 0.001). Association between distance heterophoria andheadache was not statistically significant (χ2 = 22.172; p = 0.265). The association between headache andpositive fusional vergence at near fixation was statically significant (p = 0.03). Leading cause of headache wasconvergence weakness exophoria (39.3%; p = 0.001), followed by convergence insufficiency (24%; p = 0.02).Conclusion: Headache was more common in females and was associated with exophoria, convergenceinsufficiency and inadequate positive fusional vergence at near fixation

A study of Comparison and Analysis of the Distance Subjective Associated Phoria Measured with MKH Chart, Mallett Unit and Chart Projector Cross Test with a Central Fusion Lock

Purpose : This study was intended to compare and analyze the distance subjective horizontal associated phoria using different tests. Methods : Thirty five symptomatic subjects (based on a symptoms questionnaire) were participated in this study. Distance subjective horizontal associated phoria were measured with the MKH chart, mallett unit and chart projector cross test with a central fusion lock, and minimum stereoscopic angle was measured before and after correction of fixation disparity for those subjects. Results : Distance subjective horizontal associated phoria measured with different methods such as MKH chart, mallet unit and chart projector cross test with a central fusion lock was 0.99±0.50 Δ, 0.31±0.30 Δ and 0.52±0.46 Δ, respectively, showing that there were statistically significant differences between tests(F=23.002, p=0.000). The mean of minimum stereoscopic angle before correction of fixation disparity was 85.43±54.68″. Increased minimum stereoscopic angle after correction of fixation disparity by the MKH chart, the mallett unit and the chart projector cross test with a central fusion lock was 58.00±40.21″(t=4.280, p=0.000), 75.14±54.0 9″(t=3.111, p=0.000) and 69.14±50.66″(t=2.503, p=0.000) respectively, showing that there were statistically significant differences between tests. Conclusion : There was a significant difference in the correction values of fixation disparity according to the design of the target, and after correction of fixation disparity minimum stereoscopic angle was improved significantly in all targets. In this study, minimum stereoscopic angle was improved the most after correction of fixation disparity measured with MKH chart among three targets of different designs.

Does an iPad fixation disparity test give equivalent results to the Mallett near fixation disparity test?

BackgroundVarious instruments have been developed to measure aligning prism, the prism that eliminates a fixation disparity (associated heterophoria). This includes the established Mallett near vision unit and recently developed Thomson Vision Toolbox on the iPad. With no previous research investigating the agreement between these instruments, practitioners may question if they can be used interchangeably. Methods80 participants underwent near vision testing with the Mallett unit and iPad fixation disparity test. Data were analysed in four ways to investigate the agreement of the two instruments. ResultsMany participants reported no fixation disparity (horizontally 46.25%, vertically 82.5%), or non-significant aligning prism (horizontally 70%, vertically 97.5%), on both instruments. The iPad revealed a larger range of aligning prism results horizontally, 6Δ base out to 15Δ base in; the Mallett unit produced a larger range of results vertically, 1Δ base up to 3.5Δ base down. More participants required a significant aligning prism on the Mallett unit horizontally and vertically. Wilcoxon signed rank analysis found that the difference in aligning prism was not statistically significant (p=0.357 horizontally, p=0.236 vertically), but 95% limits of agreement revealed clinically significant differences between the instruments. ConclusionAlthough the measured differences between the instruments are not significant in a Wilcoxon analysis, a Bland & Altman approach shows them to be in some cases clinically unacceptable, therefore the instruments should not be used interchangeably. Previous research indicates that the Mallett unit performs reasonably well at detecting symptomatic individuals and determining a prismatic correction that is likely to be helpful. Further research is required to determine the performance of the iPad test in these functions and to assess the reproducibility of both instruments.

Evaluation of Fixation Disparity Curve Parameters With the Modified Near Mallett Unit in Symptomatic and Asymptomatic University Students

BackgroundResearch suggests that fixation disparity data are extremely useful in the assessment of the binocular and accommodative systems.ObjectivesThe purpose of this study was to evaluate fixation disparity curve (FDC) parameters with a modified near Mallett unit in symptomatic and asymptomatic students of Paramedical Sciences School of Mashhad University of Medical Sciences in 2007.Patients and MethodsIn this analytical-descriptive study, 100 students were selected randomly and divided into symptomatic and asymptomatic groups. Fixation disparity curve parameters were determined for each subject and compared in symptomatic and asymptomatic groups.ResultsThere were more subjects with exo fixation disparity than eso fixation disparity in the study sample. The means for fixation disparity, fixation disparity curve x-intercept, and slope with the modified Mallett unit were each significantly different by Mann-Whitney U test in the symptomatic and asymptomatic groups. Also there was a significant difference in the distributions of fixation disparity curve types in the two symptom groups by Chi-square test.ConclusionsThe X-intercepts (point at which the FDC crosses the X-axis) were on average more in the base-in direction, Y-intercepts (point at which the FDC crosses the Y-axis) were shifted in the exo direction, and slopes were steeper in the symptomatic group.

Evaluation of Fixation Disparity Curve with the Modified Near Mallett Unit and the Wesson Fixation Disparity Card in Symptomatic and Asymptomatic Subjects

Purpose: The purpose of this study is the evaluation of fixation disparity curve (FDC) parameters with an instrument that includes a central fusion lock (the modified near Mallett unit) and another without one (the Wesson fixation disparity card) to determine which is useful for diagnosis of symptomatic from asymptomatic subjects.Materials and Methods: In this analytical-descriptive study, 100 students were selected randomly and divided into symptomatic and asymptomatic groups. FDC parameters were determined with the Wesson card and the modified near Mallett unit for each subject and compared in symptomatic and asymptomatic groups. Data were analyzed by Wilcoxon, Mann-Whitney U, Spearman correlation coefficient and Chi-square tests.Results: The mean slope, y-intercept, and x-intercept with the Mallett unit and the Wesson card were significantly different in the symptomatic and asymptomatic groups (p < 0.001). Significant correlations were obtained between the Mallett unit and the Wesson card in y-intercept, x-intercept and slope (p < 0.001). There was a significant difference in the distributions of fixation disparity curve types in the two symptom groups with the Mallett unit (p = 0.01) and the Wesson card (p = 0.002) by Chi-square test.Conclusions: Among symptomatic participants in this study, both Type I and Type III FD are more common than previously thought, but depend upon the method used to measure it. The x-intercepts were on average displaced in the base-in direction, y-intercepts were shifted in the exo direction, and the slopes were steeper with the Wesson FD card compared with the modified near Mallett unit. This may be related to the design of two devices. These differences were more significant in the symptomatic group.

Is the Aligning Prism Measured with the Mallett Unit Correlated with Fusional Vergence Reserves?

BackgroundThe Mallett Unit is a clinical test designed to detect the fixation disparity that is most likely to occur in the presence of a decompensated heterophoria. It measures the associated phoria, which is the “aligning prism” needed to nullify the subjective disparity. The technique has gained widespread acceptance within professions such as optometry, for investigating suspected cases of decompensating heterophoria; it is, however, rarely used by orthoptists and ophthalmologists. The aim of this study was to investigate whether fusional vergence reserves, measured routinely by both orthoptists and ophthalmologists to detect heterophoria decompensation, were correlated with aligning prism (associated phoria) in a normal clinical population.Methodology/Principal FindingsAligning prism (using the Mallett Unit) and fusional vergence reserves (using a prism bar) were measured in 500 participants (mean 41.63 years; standard deviation 11.86 years) at 40 cm and 6 m. At 40 cm a strong correlation (p<0.001) between base in aligning prism (Exo FD) and positive fusional reserves was found. Of the participants with zero aligning prism 30% had reduced fusional reserves. At 6 m a weak correlation between base out aligning prism (Eso FD) and negative fusional reserves was found to break (p = 0.01) and to recovery (p = 0.048). Of the participants with zero aligning prism 12% reported reduced fusional reserves.Conclusions/SignificanceFor near vision testing, the strong inverse correlation between base in aligning prism (Exo FD) and fusional vergence reserves supports the notion that both measures are indicators of decompensation of heterophoria. For distance vision testing and for those patients reporting zero aligning prism further research is required to determine why the relationship appears to be weak/non-existent?

The Near Mallett Unit Foveal Suppression Test: a cross‐sectional study to establish test norms and relationship with other optometric tests

When the binocular system comes under prolonged stress in decompensated heterophoria, a small suppression area can develop at the fovea. This foveal suppression (FS) may be an adaptation to eliminate symptoms. The near Mallett unit (NMU) is a hand-held instrument that contains a binocular status test for detecting and quantifying FS. We measured FS in a cross-sectional study of 131 patients to investigate the normal range of responses. A ratio scoring method was devised which considers the number of letters read with dichoptic viewing when binocularly fused (b) and under monocular (m) conditions, using the formula 100 x (m - b)/m. The 95th percentile value of the FS ratios was calculated as the limit of the normal range and this gave a value for the right eye (RE; 33%), left eye (LE; 43%) and total (38%). This result shows that statistically significant FS occurs when a patient can read approximately one line further in the test monocularly, compared to under fused dichoptic conditions. A statistically significant correlation was found between absolute values of horizontal aligning prism (associated heterophoria on the NMU) and FS ratio. Some limitations of the FS test and unexpected results became apparent during our research and an abnormal result on the test does not always indicate a binocular vision anomaly. Nonetheless, we feel that the test can provide useful information when the results are taken in the context of other clinical tests. Our results are used to develop recommendations and clinical guidelines for using the FS test, and to make suggestions for improvements in future designs of the test.

Double‐masked randomised placebo‐controlled trial of the effect of prismatic corrections on rate of reading and the relationship with symptoms

Practitioners' decisions on when to intervene in decompensated heterophoria are often based on symptoms, which are in some cases an unreliable indicator of whether an intervention will be helpful. The aim of our study was to determine when prismatic corrections improve performance at a measure of dynamic visual function: the Wilkins Rate of Reading Test (WRRT). All participants manifested an aligning prism (associated heterophoria) on the near Mallett Unit of 0.5Delta or greater. There were 80 participants, of whom 58 had exophoria, 15 esophoria, and seven hyperphoria. The effect of the aligning prism on the WRRT was compared with a control lens using a double-masked randomised design. For exophoria, an aligning prism of 2Delta and above has a sensitivity of 67% and a specificity of 79% for improving performance at the WRRT by 5% or more. It is not possible from our data to achieve a good compromise between sensitivity and specificity for the other types of heterophoria. Patients in the horizontal (but not vertical) heterophoria groups had significantly more symptoms than a control group. The patients whose visual performance is improved by prismatic correction are not necessarily those who report the most symptoms. Our data suggest that exophoric patients of any age are likely to have improved visual performance with an intervention if they have an aligning prism of 2Delta or more, even in the absence of symptoms. We stress that although the Mallett Unit Fixation Disparity test provides useful information, its results need to be considered in the overall context of the patient's symptoms, lifestyle, and the results of other optometric tests. Although this study evaluated prismatic corrections, we note that interventions for decompensated heterophoria include not only prismatic corrections, but also eye exercises and refractive modification.

The Mallett Fixation Disparity Test: influence of test instructions and relationship with symptoms

Fixation disparity is a minute ocular misalignment under conditions of binocular single vision and is typically detected in primary eye care practices in the UK using the Mallett Unit Fixation Disparity Test. This instrument creates natural viewing conditions, when the patient's binocular system is fused using both central and peripheral fusion locks. This allows the examiner to determine the minimum prism power that eliminates the fixation disparity: the associated phoria or aligning prism. The spherical power that eliminates the fixation disparity, the aligning sphere, can also be determined. The near Mallett Unit Fixation Disparity Test has been shown to have good sensitivity and specificity for detecting symptomatic heterophoria. Cases of decompensated heterophoria tend to have a fixation disparity and the aligning prism or aligning sphere is a good indicator of the correction that will render the heterophoria compensated. The purpose of this study was, for the first time, to investigate the effect of test instructions on the results of the Mallett Unit Fixation Disparity Test. In study 1, we surveyed and observed practitioners to determine the instructions that are typically used. In study 2, we compared results obtained with this "standard" method of questioning with a more "specific" form of questioning that has been suggested in the literature. The participants for study 2 were 105 patients aged 7-70 years who were randomly selected from those attending a community optometric practice. Significantly different results were obtained with the two sets of instructions. The specific form of questioning revealed more cases of fixation disparity and the results with this method showed a better correlation with symptoms. This only held for near vision: for distance vision, symptoms were not significantly correlated with the presence of fixation disparity. This agrees with previous work with the Mallett unit, which showed a significant relationship with symptoms only at near. We also found that patients with more severe symptoms had greater degrees of aligning prism. Our study supports previous work indicating that the Mallett unit is a useful tool for detecting symptomatic heterophoria at near. However, we found that the testing method is important: patients need to be asked not just whether the nonius strips are aligned but also whether one or both of the strips ever moves. More research is needed to investigate the significance of precise test instructions in other optometric and orthoptic tests.

Methods for measuring the proximity-fixation-disparity curve.

The reliability and validity of new tests of fixation disparity were investigated as a function of viewing distance (100, 60, 40, and 30 cm). The 'nonius offset card' presents a set of paired dichoptic nonius (vernier) lines with different offset simultaneously: the subject has to indicate the coinciding lines. The 'computer test' uses a psychophysical procedure that presents one pair of nonius lines sequentially with varying offset; the effect of the number of short-term nonius test trials is investigated. As a reference, the Mallett unit and the Sheedy disparometer were used. Despite different group means, the methods had significant test-retest correlations and inter-correlations, as tested at 40 cm. All methods showed an increase in exo fixation disparity as the viewing distance was shortened; the slope of this proximity-fixation-disparity curve, however, was different between the nonius offset card and the computer test.

Methods for measuring the proximity-fixation-disparity curve

The reliability and validity of new tests of fixation disparity were investigated as a function of viewing distance (100, 60, 40, and 30cm). The ‘nonius offset card’ presents a set of paired dichoptic nonius (vernier) lines with different offset simultaneously: the subject has to indicate the coinciding lines. The ‘computer test’ uses a psychophysical procedure that presents one pair of nonius lines sequentially with varying offset; the effect of the number of short-term nonius test trials is investigated. As a reference, the Mallett unit and the Sheedy disparometer were used. Despite different group means, the methods had significant test–retest correlations and inter-correlations, as tested at 40cm. All methods showed an increase in exo fixation disparity as the viewing distance was shortened; the slope of this proximity-fixation-disparity curve, however, was different between the nonius offset card and the computer test.

Fixation disparity and near visual acuity

Twenty patients having associated heterophoria values of 2 Δ and greater, as recorded with a Mallett unit, had their near monocular and binocular visual acuities measured. In the latter case, measurements were taken both with the associated heterophoria corrected by prisms and without prism correction. Bradford Near Vision charts, specially designed to measure visual acuity at near in seconds of arc, were used in the acuity measurement. The improvement of binocular acuity compared with monocular acuity was less than would occur in normal subjects without associated heterophorias. When the associated heterophorias were corrected with prisms the improvement in binocular over monocular acuity was similar to that found in normal subjects, with zero associated heterophoria readings.

Fixation disparity and near visual acuity

SummaryTwenty patients having associated heterophoria values of 2 Δ and greater, as recorded with a Mallett unit, had their near monocular and binocular visual acuities measured. In the latter case, measurements were taken both with the associated heterophoria corrected by prisms and without prism correction. Bradford Near Vision charts, specially designed to measure visual acuity at near in seconds of arc, were used in the acuity measurement. The improvement of binocular acuity compared with monocular acuity was less than would occur in normal subjects without associated heterophorias. When the associated heterophorias were corrected with prisms the improvement in binocular over monocular acuity was similar to that found in normal subjects, with zero associated heterophoria readings.

Effect of fixation disparity on distance binocular visual acuity

Subjects with appreciable values (2 delta and greater) of associated 'phoria, as measured by a Mallett unit, had their distance monocular and binocular visual acuities measured. In the latter case measurements were taken both with the associated 'phoria corrected by prisms and without such a correction. The improvement in binocular acuity compared to monocular acuity was less than would occur in normal subjects with minimal associated 'phorias although the improvement differed accordingly as to whether the readings were eso- or exo-in mature. When the associated 'phorias were corrected with prisms the improvement in binocular over monocular visual acuity was similar to that found in normal subjects.