Reverse exercises in a case of intractable diplopia.

The aim of this presentation is to highlight how orthoptic exercises can be adapted from the standard implementation and gain results in an intractable diplopia case. A 16-year-old male presented with a 20 prism diopters residual right esotropia and intractable diplopia following Surgery and Botulinum Toxin. Having had further BT and surgery ruled out and no success with Fresnel prisms or occlusion, he commenced on standard orthoptic exercises without success. Additional orthoptic assessment discovered that the patient could achieve binocular single vision (BSV) on convergence at 10 cm. The patient then proceeded on a course of exercises to help extend this area of BSV. These exercises included a reverse dot card and a variation of the distance cat stereogram. Over the next couple of visits, the area of binocularity was extended to 30 cm and the esotropia measured 18 prism diopters. However, the patient felt that progress was slow, and they were keen to learn to drive and so opted for an occlusive contact lens instead. It is unfortunate that the patient did not continue with the exercise program as it showed potential to increase his area of BSV. However, this case does demonstrate how utilizing current knowledge concepts of both exercises and BSV, and adapting them to a specific patient could lead to improvement in the likes of intractable diplopia and be a potential management option.