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pippistrellodaqua, Optometrist
Category: Eye
Satisfied Customers: 134
Experience:  Specialty in contact lenses, medical eye management, LASIK
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[Question for top eye doctor.]Please only respond if you

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[Question for top eye doctor.]

Please only respond if you are sure of the answer, thank you.

Let’s assume there is a person with perfect vision, and they are viewing an object 20 feet away. Their accommodative muscles then contract (to say a distance of 12 inches), causing the distant object to appear blurry. If that person then pin-holes, will the object become clear? Why or why not?

I understand pin-holing negates some astigmatism and refractive error, so won’t it do the same for accommodative spasm, or is the curvature of the lens too great?
Submitted: 1 year ago.
Category: Eye
Expert:  Dr. Rick replied 1 year ago.
Hi. I'm online and happy to answer your question today.

Yes. The object will become clear.

With a pin hole refractive error doesn't matter, even if it is induced by accommodative action, since only parallel light beams are entering into the eye.

The lens no longer figures into the equation with a pin hole system.

Please remember the top 3 ratings are positives and Excellent service is my goal. Your positive feedback is how we are compensated. If you aren't 100% satisfied, just click "reply." I will be happy to discuss your issue in more depth and do everything I can to provide you with the information you require.
Otherwise, a high positive rating is very much appreciated, bonuses are great, and find me anytime for follow up.

Let me know if you have further questions.
Customer: replied 1 year ago.

Ok, so you're saying that since the image does not get clearer when I pin-hole, it means the blurriness is not due to over-accommodation as the doctors suggested?


 


That's what I'm trying to get at with this question.


Because, if it's not due to over-accommodation, what could it be?


...and we can rule out all permanent conditions, like cataracts, retina, etc, because I can make the distant image very clear simply by straining (I'm not referring to squinting), although this becomes tiresome and give me a bad headache.


 


(They said I have no refractive error, no cataracts, healthy retina, healthy brain MRI, and my astigmatism is insignificant, yet the largest letter on the chart is just a blur, unless I strain really hard or I'm dilated)

Expert:  Dr. Rick replied 1 year ago.
The image will become clearer with pinhole if the problem is due to refractive error from any source.

If it doesn't get clearer then something else is going on.

It was a pleasure to be able to help you today. If you would be so kind, please help me get credit for my efforts in answering your questions and press the excellent feedback button for this encounter.
Customer: replied 1 year ago.

Right, that's what I'm saying my question is. Please take another read.

Expert:  Dr. Rick replied 1 year ago.
I'm not sure I understand what you are asking. I will opt out so that another doctor can assist you.
Expert:  Camille-Mod replied 1 year ago.

Hi, I’m a moderator for this topic. Your Professional has opted out and I wonder whether you’re still waiting for an answer. If you are, please let me know and I will do my best to find another Professional to assist you right away. If not, feel free to let me know and I will cancel this question for you. Thank you!

Customer: replied 1 year ago.

Yes, I'm still waiting on an answer to find out what could be causing my blurry vision if it's not due to over-accommodation.

Expert:  Camille-Mod replied 1 year ago.

Thank you. Sometimes, finding the right Professional can take a little longer than expected and we thank you greatly for your understanding. We’ll be in touch again shortly. Please do not respond to this as it will prevent the Professionals from accessing your question. Thank you.

Expert:  pippistrellodaqua replied 1 year ago.
I've been thinking about this question for some time now. Dr. Rick said it correctly. If a patient who sees 20/20 at distance accommodates at near and has made the distant object blurry then places a pin-hole over the eye both the distance and near objects should clear up unless there is some other disease type condition present. A patient with spasm of accommodation should clear up at distance when given a pin-hole.
I just verified this with one of my staff members by placing lenses over the eyes which will induce accommodation and had them look at a near object. The near object was clear, while the distant object was blurry. I then placed a pin-hole over theirs eyes and both distant and near objects cleared up.
Customer: replied 1 year ago.

Yes, this is what I thought also and why I think the issue is not due to accommodation like they suggested. And this is the reason I'm asking the question. Thanks for taking the question, do you know the answer?

Expert:  pippistrellodaqua replied 1 year ago.
Unless I'm missing something your questions are these:
1. If that person then pin-holes, will the object become clear? Yes.
2. Why or why not? Again, the parallel light answer.
3. I understand pin-holing negates some astigmatism and refractive error, so won’t it do the same for accommodative spasm? Yes it does.
4. or is the curvature of the lens too great? No the lens would be ignored in this scenario.
As you said, there are no other conditions which have been detected to explain the pinhole problem.

"...and we can rule out all permanent conditions, like cataracts, retina, etc, because I can make the distant image very clear simply by straining (I'm not referring to squinting), although this becomes tiresome and give me a bad headache.


(They said I have no refractive error, no cataracts, healthy retina, healthy brain MRI, and my astigmatism is insignificant, yet the largest letter on the chart is just a blur, unless I strain really hard or I'm dilated)"


The only other thing that I would suggest has probably already been done (or should have been done by now), but would be a cycloplegic refraction where the "big boy" drops are used (cyclopentolate) to knock out any remaining accommodation and determine if there is any remaining refractive error which has been masked in the normal refraction.

I'm not sure what else you're looking for, but I'm more than happy to continue to answer follow-up questions. Positive ratings are always appreciated.
Customer: replied 1 year ago.

That's ok, there must be a problem with the website that it is not showing you my question, which I sent to JustAnswer several times. It was: "what could be causing my blurry vision if it's not due to over-accommodation?" I already knew the answer to the pin-holing question, I was just confirming it prior to asking my question.


 


(The drops I've used are Atropine for 2 weeks. Are they strong enough like the drops you mentioned? What I don't understand, is the drops made distance less blurry, which suggests over-accommodation, but pin-holing does not improve distance, which suggests it's not over-accommodation.)

Expert:  pippistrellodaqua replied 1 year ago.
Atropine would do it. And you're correct that if it improves the distance by using atropine that over-accommodation is likely. Pin hole works well but only to a certain extent. Most patients who improve with pinhole will only do so to about 20/30 or so. It's possible that the pin hole will not clear the vision while over-accommodation is to blame if the over-accommodation is responsible for a 20/30 or so blur (and not much worse.) If you're more blurry than 20/30 and the pin hole doesn't clear things up we could effectively rule out refractive error and in that case the cause of your blur could be any number of things. I think you may have already suspected this, though, and I am unable to answer the question definitively.
Customer: replied 1 year ago.

I can not read the largest letter on the chart, so I'm guessing that is worse than 20/30? If that's the case, then is sounds like it's something more than over-accommodation, and so I'm looking to know what it may be.

Expert:  pippistrellodaqua replied 1 year ago.
The big letter will be 20/400 or 20/200. If that letter doesn't improve on pin-hole then there must be a reason for it. Is it just one eye or both that cannot read the large letter? Has the eyes alignment been evaluated? Is this a sudden decrease in vision or has it always been this way? There are literally thousands of conditions that can cause blur and it would be impossible to diagnose them without an examination. It sounds like the doctors have already looked for medical reasons for your blur. By answering my questions I may be able to give you a better idea of where to go from here.
Customer: replied 1 year ago.

Thanks. Yes, the issue is present in both eyes equally, while the other is covered. (this means it's not due to alignment, right?)


 


It was not sudden. It began faintly in 2006 when I noticed I got tension headaches from straining when at places like movie theaters. It has gotten worse each year, and now I can barely see at all. The only time I notice it change, is that it gets worse when there is much going on visually, like when in a car or the isle of the supermarket. It also gets worse when I notice the blurriness and think about the fact it's occurring.


 


Regarding the pin-hole, it does not make the image clear, but I do notice that when pin-hole it requires less straining and effort to get the blurry image into focus. So to express this observation in another way... with no pin-hole it requires a lot of straining to get image into focus, and with the pin-hole it requires a medium amount of straining.

Expert:  pippistrellodaqua replied 1 year ago.
"Regarding the pin-hole, it does not make the image clear, but I do notice that when pin-hole it requires less straining and effort to get the blurry image into focus. So to express this observation in another way... with no pin-hole it requires a lot of straining to get image into focus, and with the pin-hole it requires a medium amount of straining."

But, at some point it does clear up? To what acuity level does it clear? Can you eventually read the lower lines after you put effort into it or is it blurry always?

If your vision does clear up at any point with focusing or with pin-hole by glasses or by whatever means then there should be some way of correcting it either with spectacles or vision therapy. If the vision never clears whatsoever and all other disease eye conditions have been ruled out then the only thing I can think of to check would be neurological.

There are several neurological conditions which do not show up as problems on MRI or other scanning procedures but which can affect the vision. The eye acts as a camera to capture light. Processing of that light does start at the back of the eye, but most of the processing begins after the optic nerve has transmitted that information to the brain.

Again, if the vision ever clears up via pin-hole or spectacles, then there should be a way to maintain that cleared vision. If, as I think you're saying, it does not completely clear then the source of the problem is likely behind the retina and lies somewhere between the back of the eye and the back of the brain, in which case a neurologist would be your next stop.

I hope this has helped you in some way sort out what may be happening. I have put in a lot of effort in helping you and am committed to helping you as much as possible. Please consider a positive rating; it would be much appreciated. Please don't hesitate to contact me again if there are further concerns.
pippistrellodaqua, Optometrist
Category: Eye
Satisfied Customers: 134
Experience: Specialty in contact lenses, medical eye management, LASIK
pippistrellodaqua and other Eye Specialists are ready to help you
Customer: replied 1 year ago.

Yes, I am giving the highest rating now. And then we can continue with this follow-up:


 


I am able to get images much clearer by straining. Using pin-hole reduces the amount of straining required and results in an even clearer image than without pin-hole, but the fact remains that straining is required.


 


So what I understand you saying, is since clarity is possible (by combining straining and pin-hole), it's a "refractive" issue and should be correctable? It seems to make sense that my issue might be due to over-accommodation (though I would expect more improvement from pin-hole if that were the case). Does over-accommodation sound like the likely cause in my case, and if so, how can I stop it from occurring? Maybe specific eye drills I can do each day?


 


I tried -4.50 lenses, and they make distance clearer, but then I can't see anything near to me. I tried dilating drops, but then I'm too photo sensitive and can't see screens or when outside, even with dark sunglasses. Also, with my pupil that large, my lasik scar (15 yrs ago) causes distortion. So being dilated was just as bad or worse than not dilated.


 


 

Expert:  pippistrellodaqua replied 1 year ago.
Yes, since you are able to clear it up by either straining or pinhole the issue is likely refractive in nature. Accommodative spasm can cause a blurring at distance and is consistent with your descriptions. Minus power lenses will clear things up briefly in accommodative spasm, but you'll actually need plus lenses to help you relax the accommodative system. Even better would be to perform a technique called Accommodative Rock. I have seen vision therapy kits on Ebay which include all of the equipment needed. I don't see them now but perhaps they will show up again. Accommodative Rock will help patients control their accommodative system. It takes some effort, but it may be worth it to see if accommodation is truly the problem.
Customer: replied 1 year ago.

Thanks for making me aware of the technique Accommodative Rock. I've researched it, and see it can be done with flippers or near and far Hart charts, but it seems this technique is designed to increase the patient's ability to accommodate as well as speed up the accommodative response. They say it will help the patient achieve focus at reading distance, and quickly switch from distance to near. I think I need the opposite... meaning a technique to release/relax the state of accommodation, and help me switch from near to distance. So in that case, what technique would be good to use?


 


(e.g. a method to decrease the tendency of positive accommodation and restore the ability of effortless negative accommodation.)


 


 


I notice that when my eyes are over-accommodated, they are also over-converged (crossed). I'm thinking the over-convergence will resolve as the over-accommodation is resolved because it's just following in harmony with the accommodative system? Or should a technique be used to address the convergence issue as well?

Expert:  pippistrellodaqua replied 1 year ago.
Great questions. Yes the Accommodative Rock usually is used for a lack of convergence, but it really trains something called "facility" which is the ability to go from a converged to non-converged or vice-versa state. If you believe that you have convergence problems as well I suggest getting a Brock String as well.

You'll find that most training exercises deal with the inability to converge or the inability to accommodate. Yours may be the opposite problem. These trainings can be used exactly in opposite to stimulate divergence and relaxation. Additionally you may want to search for an aperture rule, which would be used specifically for divergence.
Customer: replied 1 year ago.

When you said:


"Accommodative Rock usually is used for a lack of convergence"


did you mean:


"Accommodative Rock usually is used for a lack of positive accommodation"


because that's what it looks like the technique is used for.


 


When you say: "These trainings can be used exactly in opposite to stimulate divergence and relaxation", how does one use them in the "opposite"?


 

Expert:  pippistrellodaqua replied 1 year ago.
Most of these techniques can be used to stimulate or work on positive or negative vergences as well as positive and negative accommodation. The Accommodative Rock would require more plus lenses than minus lenses and the vectograms or aperture rule can work on divergence just as well as convergence. Most binocular vision problems are due to a lack of convergence or lack of accommodation (hence the terms convergence insufficiency and accommodative deficiency) so most of these tools are geared towards these problems. It is quite simple to perform these techniques in the reverse however.
Customer: replied 1 year ago.

OK, thanks. I will give another excellent rating.


but I asked how to do them "opposite" and your reply was to do them "in the reverse". These terms do not make it clear to me how specifically I should do them differently than they were designed.

Expert:  pippistrellodaqua replied 1 year ago.
You're right that is a bit ambiguous. Each tool will be set up slightly different. For example, the Brock String. When training for convergence a bead will be brought closer to your nose and as you keep it clear and single will stress those positive vergences. If you instead push the bead away from you and keep it clear, relaxed and single it will stress the negative vergences.
Another example is with the aperture rule. When training convergence the eyes will focus in front of the target and you'll get a cross eyed feeling. When training divergence there are two apertures instead of one to help you get a feeling of relaxation and a wall-eyed feeling. That is what I mean by doing the opposite or reverse procedure and most of these tools can be easily modified to do both (or already come made to do so.)
A final tool would be a vectogram, which is worn with red/green or polarized glasses. I haven't used one in a while, but when pulling the targets apart in one direction it will stimulate convergence and accommodation, while if you pull it the other direction it will stimulate divergence and relaxation.
Hope that helps.
pippistrellodaqua, Optometrist
Category: Eye
Satisfied Customers: 134
Experience: Specialty in contact lenses, medical eye management, LASIK
pippistrellodaqua and other Eye Specialists are ready to help you
Customer: replied 1 year ago.

Great, I gave an excellent rating for that one too.


 


When I went to places like Mayo and University of NY, they noted it puzzling that my vision changes when switching between my normal “relaxed” state, and a strained state, were the opposite of text books and how the system should supposedly work. (relaxing produced positive accommodation and convergence, while straining produced negative accommodation and divergence). What does the fact that it's the opposite of what's expected tell us?


 


Does the above observation match up and in agreement with the theory that my blurry vision is due to my muscles being locked in positive accommodation? If yes, then I ask the following:


 


When I strain very hard (not squint), I can compensate for the fact my accommodative muscles are locked in a tensed state. The feeling of this "staining" is hard to describe, but it's like the muscles of my eye-socket are squeezing the eye-ball, and maybe even increasing its internal pressure.


 


What am I doing to accomplish this? Could I be coordinating the tensing of all the extraocular muscles simultaneously in order to pull the eye inward and shorten the distance between the lens and the retina, therefor compensating for the excess lens curvature caused by the tensed accommodative muscles? What other structural mechanisms are there? Does there exist other muscles of the eye, that when tensed, could act to flatten the lens?

Expert:  Camille-Mod replied 1 year ago.

Hi, I’m a moderator for this topic. It seems the professional has left this conversation. This happens occasionally, and it's usually because the professional thinks that someone else might be a better match for your question. I've been working hard to find a new professional to assist you right away, but sometimes finding the right professional can take a little longer than expected. I wonder whether you're OK with continuing to wait for an answer. If you are, please let me know and I will continue my search. If not, feel free to let me know and I will cancel this question for you. Thank you!

Customer: replied 1 year ago.

still waiting for answer from current expert.

Expert:  Camille-Mod replied 1 year ago.

Hello:

Thank you for your reply. To better serve you, I will forward your questions to Customer Service where a Customer Service Representative will contact you via email.

Expert:  pippistrellodaqua replied 1 year ago.
I have been thinking for several days about your last question. I have never seen a patient who's vergence and accommodative systems work against the normal. I am unsure of the logic of the following questions because, to me, they are theoretical (that is since I have never seen or heard of the problems working in opposite of how they should, it would be mere speculation for me to comment further.) There is a doctor I met at Ohio State University who may know more. If anybody knows it would be Dr. Earley at Ohio State. I wish you the best, XXXXX XXXXX maintain high confidence in my answers I must opt out.
Customer: replied 1 year ago.

OK, hopefully he responds.

 

For many years I've had problem of red eyes just like you see here:

http://listverse.files.wordpress.com/2008/06/eyeball2-7apr07.jpg http://www.firehow.com/images/stories/users/80/red-eye-cure.jpg

 

I avoid "red-eye" drops, because the relief is only temporary and don't want to make the situation worse by weakening the blood vessels and creating a rebound effect. I eat healthy, take vitamins, anti-oxidants, flax oil, etc, and have tried using artificial tears.

 

 

 

Expert:  pippistrellodaqua replied 1 year ago.

The pictures you posted appear to be mild forms of episcleritis, which is a condition that causes an engorgement of the blood vessels on the front white surface of the eye. Episcleritis usually is not painful and is not associated with any discharge of the eye. It usually affects only a section of the white part of the eye.

The pictures you displayed are not associated with a mass of tissue called a pinguecula, which is much more common than episcleritis. Check this picture to see if it resembles your eyes.

http://lasereyesurgeons.net/pinguecula

Look for an elevated region or even a yellowing underneath the dilated blood vessels. If it is a pinguecula then it can be removed via surgery.

Episcleritis requires treatment, usually with steroid drops, which would require a visit to your optometrist or ophthalmologist. Differentiation between the two conditions (episcleritis or pingeucula) can be easily made with an examination.

Expert:  pippistrellodaqua replied 1 year ago.
This is a separate problem to that which we have been discussing over the past few weeks. I'll opt back in for this question if you desire.
Customer: replied 1 year ago.

There's no elevation or yellowing, so I don't think it's pinguecula.


Also, it's not a particular area of the eye like episcleritis.


It's more so visible vessels spread evenly around all white areas of both eyes. Like: http://i.istockimg.com/file_thumbview_approve/10078342/2/stock-photo-10078342-close-up-blood-shot-eye.jpg


 

Expert:  pippistrellodaqua replied 1 year ago.
This picture you sent looks much more normal. Though the vessels are more pronounced, there doesn't appear to be any problem whatsoever with this photo. I have recently read of a procedure that may be able to help with this kind of problem. The procedure usually removes melanin or pigment. Though I have never seen a patient who has had it done (just one doctor in the US so far as I know does this procedure) this article explains things quite nicely. Other than the "get the red out" drops (which I do not recommend for the long-term) there is no other way to eliminate this appearance.

http://www.revoptom.com/content/c/27071/
Customer: replied 1 year ago.

So not Acular or something else?


 


Some sources suggest it could be a symptom of my Crohn's Disease. Could the other vision issues be from Crohn's too, or no?

Expert:  pippistrellodaqua replied 1 year ago.
Not Acular, which is an NSAID and is used to cut inflammation. It is used almost exclusively for post-surgical management and allergies. Rarely is it used for pain of the eye.

Crohn's disease can be very related to episcleritis we talked about before. Other ocular features of Crohn's includes uveitis, conjunctivitis, corneal involvement, and retinal inflammation. These problems usually wax and wane and require treatment with steroid medications.
Customer: replied 1 year ago.

ok, thanks, XXXXX XXXXX rate now.


To be sure I understand:


 


1. To clarify, my issue is not pain, just redness (maybe my dust allergy is a contributor, though they do not itch). Would Acular still not apply? If it does apply, is there a disadvantage to long-term use?


 


2. So you're saying Crohn's could be causing my blurry/double vision issues, or you're saying no, because if that were the case I would notice waxing and waning over the months?


 

Expert:  pippistrellodaqua replied 1 year ago.
1 - If we can rule out the idea of episcleritis which is usually painless, then Acualr is not indicated. Long-term consequences of ocular NSAIDs like Acular include a decrease in corneal sensitivity, which can cause problems in the future.

2 - I'm saying that Crohn's is unlikely to be contributing to the other issues we have discussed. Unless, again if it is episcleritis that is causing the redness Crohn's is not likely to blame. I do not think that Crohn's could be causing the double vision/blur issues.
pippistrellodaqua, Optometrist
Category: Eye
Satisfied Customers: 134
Experience: Specialty in contact lenses, medical eye management, LASIK
pippistrellodaqua and other Eye Specialists are ready to help you
Customer: replied 1 year ago.

ok, so I guess the botXXXXX XXXXXne is there's nothing I can do to reduce the red in the whites of my eyes?


 


----


 


From what I understand, they are giving you credit for each of these you answer; so if that is the case, I have another one for you that's right up your ally.


 


 


I bought some boxes of contacts, based on a trial pair I have, and I'm thinking I should take advantage of my opportunity to return them and get a full refund. Please give your comment based on the situation...


 


Contacts are mild Proclear Torics:


PL | -0.75 | 130


+0.5 | -0.75 | 30


 


They give me a small improvement in distance clarity, so that once I do correct the main issue of over-accommodation by straining (or in the future, vision therapy), they provide the small additional correction needed as determined by cycloplegic refraction exams.


 


But my question is this, they tend to drift around my eye creating frequent blurriness, and the next day my eyes are VERY dry for some reason, before I even put them back in. These two negatives seem to out weigh the small added clarity they provide. Are these things always going to exist for me because it's how I personally mix with contacts, or will these negatives go away after a few weeks? (I don't remember having these negatives when I wore contacts 20 years ago, but that was a long time, so I could have forgotten.)


 


I'm thinking to NOT use them... unless you feel these issues always go away, and perhaps the extra clarity they provide will help prevent my therapy-corrected accommodation problem from coming back?


 

Expert:  pippistrellodaqua replied 1 year ago.
Proclear is the only lens approved by the FDA for dry eyes. When factoring the astigmatism into the prescription you do indeed have a very mild prescription. There are 1.5 "clicks" of prescription in the right eye and about a half of a click in the left. Most folks start to notice a difference at 1 click of prescription. I would rarely give a prescription for such a small amount of demand, especially when considering the dryness and discomfort of the contact lenses. By the same token, this RX is a very small amount and would not likely contribute to the accommodative issue. With any prescription (or any decision in general) the benefits must outweigh the risk/cons to be worth pursuing. If you notice only a marginal improvement at distance and we can safely say that the accommodative system should not be influenced much by such a small prescription, then the benefit is small. Again, with most folks, I will not pursue contact lenses for such a small amount of prescription.
Customer: replied 1 year ago.

ok thanks, XXXXX XXXXX plan to return the contacts, because you're saying their discomfort/movement and dryness are not likely to go away after a period of time, right?


 


And you're also saying there's nothing I can do to reduce the red in the white's of my eyes? right?

Expert:  pippistrellodaqua replied 1 year ago.
When fitting contact lenses I always allow a trial period of 2-3 weeks to determine if the comfort of the lens is going to work. Comfort or movement issues that are still there after a few weeks are unlikely to get better on their own.

Again, if the redness is due to inflammation such as episcleritis or even allergies it could be treated. If the redness you note is like the last picture you posted, which looks rather normal with more pronounced blood vessels then there isn't any treatment.
pippistrellodaqua, Optometrist
Category: Eye
Satisfied Customers: 134
Experience: Specialty in contact lenses, medical eye management, LASIK
pippistrellodaqua and other Eye Specialists are ready to help you
Customer: replied 1 year ago.

I found a source like this for flippers:

http://optego.com/index.php?page=shop.product_details&flypage=flypage.tpl&product_id=17&category_id=12&option=com_virtuemart&Itemid=8

 

But wondering two things..

 

1. If I was to buy 3 of them, which powers should I get?

2. Since my issue requires use of the plus powers, couldn't I just get readers from my local store and lift them up and down in front of my eyes to create cycles?

 

(and here's a site with lots of options: https://www.good-lite.com/Details.cfm?ProdID=733&category=0&Secondary=0 )

Expert:  pippistrellodaqua replied 1 year ago.
If you were to get 3 flippers I'd start with the +/-1.00, +/-1.75 and +/-2.50. This should give a good range of plus powers, though you're correct about the readers. You'll likely find no benefit from the minus side of the 2.50 flippers.

The Good-Lite site is a good one. The lifesaver cards you linked are great for convergence and divergence therapy. Use the opaque white card for convergence and the clear one for divergence.

I would also suggest looking for a Brock string (very inexpensive) and possibly an aperture rule (very efficient.)

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