ICEID EYE CENTRE

Binocular Vision Assessment

1. Patient Biodata

2. Convergence Insufficiency Symptom Survey (CISS)

Please answer the following questions about how your eyes feel when reading or doing close work.

Question Never
0		 Infrequently
1		 Sometimes
2		 Fairly Often
3		 Always
4
CISS Total Score: 0 / 60

3. COVD Quality of Life Symptom Checklist

Check the response that best represents the occurrence of each symptom.

Never = 0    Seldom = 1    Occasionally = 2    Frequently = 3    Always = 4

Symptom Never
0		 Seldom
1		 Occasionally
2		 Frequently
3		 Always
4
COVD Quality of Life Total Score: 0 / 120
Interpretation: Complete the questionnaire.

Score interpretation:
Below 15: Routine eye care examination.
16-24: Visual functional problem - referral to a developmental optometrist indicated.
25 or above: Refer for developmental vision evaluation.

4. Visual Acuity & Refraction

5. Ocular Alignment

6. Near Point of Convergence (NPC)

7. Fusional Vergence

TestBlurBreakRecovery
Distance Base Out (BO) / Positive Fusional Vergence (PFV)
Distance Base In (BI) / Negative Fusional Vergence (NFV)
Near Base Out (BO) / Positive Fusional Vergence (PFV)
Near Base In (BI) / Negative Fusional Vergence (NFV)

8. Accommodation

9. Sensory Binocular Vision

10. Ocular Motility

11. Additional Investigations

12. Diagnosis

13. Management Plan

14. Clinician Details