Diagnosing learning related vision problems

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Presentation given at the Vision's Impact on Learning Conference 9-11

Presentation given at the Vision's Impact on Learning Conference 9-11

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  • 1. Diagnosing and Treating Diagnosing and Treating Learning Related Vision ProblemsLearning Related Vision Problems What do Doctors do (or should do) to Dominick M. Maino, OD, MEd, FAAO, FCOVD-A diagnose LRVP? Professor Where’s the research? Illinois Eye Institute Illinois College of Optometry What Therapy Procedures Should I Private Practice Use? Harwood Heights, Il. What’s New? BV Dx & Tx in the News!! 3 4 3 D Movie Stars…Can’t See 3D! 5 6
  • 2. 3-D TV and Movies Look to Attract Viewers But Not Healthbeat Report: The 3-D Dilemma Everyone Can See What All the Hype is About 7 8 3 D Classroom! Non-strabismic BV disorders…Studies have shown that the measurable Prevalenceeducational benefits of presenting teaching Prevalence of General Dysfunctions in Binocular Vision . Montés- Micó Robert. Annals of Ophthalmology, Volume 33, Number 3,materials in 3D are significant, generating a September 2001 , pp. 205-208(4). (Spain)threefold improvement in comprehension andretention over the more traditional non - 3D …in 1679 subjects aged 18 to 38 years. …. A high prevalence of binocular vision dysfunctions wasstyle of presentation. And students respond found. … 56.2% presented symptoms of binocularwell to the immersive and engaging qualities of dysfunctions, 61.4% with accommodationthe 3D effect … disorders and 38.6% vergence disorders. Accommodation insufficiency was most prevalent AOA/3D@Home among those with symptoms (11.4%). … www.3Dhealth.org 9 10 BV disorders BV disorders Prevalence Prevalence Prevalence and risk factors for common visionPickwells Binocular Vision Anomalies By Bruce problems in children (in the UK) J. W. Evans, David PickwellBetween 1 in 5 to 1 in 10 individuals have …for 7825 seven-year-old children. BV problems. 30-60 million people 2.3% had manifest strabismus, 3.6% had …amblyopia…. 11 12
  • 3. Non-strabismic BV disorders BV disorders PrevalenceGeneral binocular disorders: prevalence in a clinic population. Ophthalmic & Prevalence: Additional Articles Physiological Optics. 21(1):70-74, January 2001.Lara, Francisco 2; Cacho, Pilar 1; Garcia, Angel 1; Megias, Ramon 2 Prevalence of general binocular dysfunctions in a….W We examined 265 symptomatic patients …., 59 i d t ti ti t population of university students. students patients (22.3%) had some form of accommodative or binocular dysfunction …. The frequency of binocular dysfunctions was 12.9%, and 9.4% for 32.3% of the subjects showed general accommodative anomalies. Convergence excess (4.5%) was more prevalent than convergence binocular dysfunctions insufficiency (0.8%) and accommodative excess (6.4%) more prevalent than accommodative 13 14 insufficiency (3%). BV disorders BV disorders Prevalence: Additional Articles Prevalence: Additional Articles Stereoacuity levels and vision problems in hild i children from 7 to 11 years f t Prevalence of amblyopia in ametropias in a clinical set-up …prevalence of defective stereoscopic vision was found to be between 2.1 and 3.2 per cent (5.97%) …Out of 970 ametropic eye patients a total of 56 patients have amblyopia…. 15 16 Non-strabismic BV disorders What Does the Prevalence • Convergence Insufficiency: 1.3% to 37% of Doctor Do to the population; most report 3-5% • Convergence Excess: ~6% Diagnose Learning • Accommodative disorders: 3-5% AOA: Care of the Patient with Accommodative and Vergence Dysfunction Related Vision http://www.aoa.org/documents/CPG-18.pdf 17 Problems? 18
  • 4. Can We Measure Symptoms Can We Measure SymptomsTest-retest reliability of the college of optometrists in Evaluating Changes in Quality of Life After vision development quality of life outcomes Vision Therapy Using the COVD Quality of assessment. MAPLES W. C. , et al. Life Outcomes Assessment Kelly M. Daugherty, OD, et. al.The COVD Quality of Life Outcomes Assessment is a reliable tool to measure changes in symptoms on The COVD – QOL Questionnaire in a socially at- the basis of optometric intervention-specifically, risk population of youth Willard B. Bleything, vision therapy OD, MS, FAAO, FCOVD, Sandra L. Landis, OD, FCOVD 19 20 Subjective Complaints of Can We Measure Symptoms Patients with BV DisordersValidity of the convergence insufficiency symptom survey: a confirmatory study. • BlurRouse M, Borsting E, Mitchell GL, et al. , g , , • Headache d h • Aesthenopia…The CISS continues to be a valid • Diplopia instrument for quantifying • These complaints are usually symptoms in 9 to <18-year-old associated with near work children… 21 22 Subjective Complaints of Subjective Complaints of Patients with BV Disorders Patients with BV Disorders • Blur • Blur •H d h Headache • H d h Headache • Aesthenopia • Aesthenopia • Diplopia • Diplopia • These complaints are usually associated • These complaints are usually with near work associated with near work 23 24
  • 5. Subjective Complaints of Examination Sequence Patients with BV Disorders Comprehensive Eye/Vision Examination• Blur• Headache H d h Visual Efficiency Examination• Aesthenopia• Diplopia• These complaints are usually Vision Information Processing Examination associated with near work 25 26 Examination Sequence Examination Sequence Comprehensive Eye/Vision Examination Visual Efficiency Evaluation HX History (Sy pto s e ated (Symptoms related to near wo , school, ea work, sc oo , sports, BV dysfucntions, etc.) Visual Acuity VA Oculomotor/Entrance Tests Oculomotor System Sensory Fusion System Refraction Motor Fusion/Vergence System Accommodative System Eye Health 27 28 Visual Visual Efficiency Efficiency Examination Examination 29 30
  • 6. Examination Sequence Vision Information Processing Examination Laterality/DirectionalityVisual Information Processing Non-motor VIP Visual Information Processing Motor Oculomotor Auditory Information Processing Misc. 31 32 Master VIP Problem List 33 34 Visual Efficiency Examination: Basic Tests History Master Problem List Must be M b geared towards the child or d d h hild adult with likely binocular vision dysfunction, learning related vision problems or work/recreational related functional vision anomalies. 35 36
  • 7. Visual Efficiency Examination: Visual Efficiency Examination: Basic Tests Basic Tests • Visual acuity – May find reduced Refraction acuity at it t near or complaints of Control Lens blur at near (intermittent problems) 37 38 Visual Efficiency Examination: Visual Efficiency Examination: Basic Tests Basic Tests Oculomotor System Developmental Eye Movement Test DEM J . TASSINARI Pursuits, S P i Saccades d Developmental Eye Movement Test: reliability and symptomatology .Developmental Eye Movement Test Journal of the American Optometric Association ,2005; DEM Volume 76 , Issue 7 , Pages 387 - 399 Visagraph/Readalyzer 39 40 Visual Efficiency Examination: Visual Efficiency Examination: Basic Tests Basic Tests • Cover test • Nearpoint of convergence – Repeat several times –Distance and near – See what happens with –Repeat during the fatique exam to see if – Red lens sensitive for CI fatigue changes A prospective study of different test targets for your result the near point of convergence Yi Pang, Helen Gabriel, Kelly A. Frantz and Faheemah Saeed 41 42
  • 8. Visual Efficiency Examination: Basic Tests Other tests Heterophoria 2 Degree Fusion In Phoropter Prism Bar Suppression S i – Worth 4 DotRisley Prism/Madox Rod 43 44 Accommodative Basic tests amplitude Basic testsStereopsis – Either push-up, push away methods or Look for reduced steropsis minus lens Less th L than 70 seconds of arc d f method – Minimum amplitude = 15 - (0.25) age The minus lens method – So a 20 year old exhibited the best repeatability... should have at least Repeatability intra-examiner and agreement in 10 diopters of amplitude of accommodation measurements accommodation Antona B, Barra F, Barrio A, Gonzalez E, Sanchez I. 45 43 Basic tests Basic tests• Accommodative facility NRA – Perform monocularly and binocularly Negative Relative with suppression control (+/-2 00) (+/ 2.00) Accommodation • ~10 cycles per minute is diagnostic PRA For children with reading problems: Positive Relative Binocular accommodative facility values were significantly lower (p < Accommodative function in school children with reading Accommodation difficulties. Palomo-Alvarez C, 0.05) in the poor readers (4.9 cpm +/- Puell MC. 3.1) than controls (6.3 cpm +/- 2.9) 47 48
  • 9. Basic tests Other Tests• Vergences • Dynamic Retinoscopy – Use either prism bars or –Monocular Risley prisms Estimation Method – Sheard’s criteria –Expected Values: • Need twice your phoria in reserve –+0.50 to +0.75 D • Example: a 10 pd exophore at near needs 20 pd BO 49 50 reserves Other Tests Other Tests • Fixation Disparity • Fixation Disparity Testing Testing – Wesson Card – Wesson Card – Bernell Fixation – Bernell Fixation Disparity (Associated Disparity (Associated Phoria) Phoria) – Disparometer – Disparometer 51 52 Other Tests Other Tests • Fixation Disparity Testing – Wesson Card – Bernell Fixation Disparity (Associated Phoria) – Disparometer 53 54
  • 10. 55 56 Common BV Syndromes Convergence Insufficiency• Convergence Insufficiency • Signs: – Most common syndrome – An exodeviation at near • Can even be an intermittent exotropia at near – Symptoms: aesthenopia, – Receded NPC value headaches, blur, diplopia, loss • NPC larger than 10 cm of concentration – Reduced BO vergences at near • associated with near work • Often fail to meet Sheard’s criterion • often occur near the end of the day 57 58 Convergence Excess Convergence Excess • Symptoms: Diplopia, headaches, • Signs aesthenopia – Dynamic Retinoscopy – almost always near related • May be the most significant test • Signs: • Typically a high lag of accommodation – Esophoria at near • Use detailed accommodative target or you may miss • Lag may be +1.00 to +2.00 DS at 40 the esophoria cm – Vergences • Lags greater than +2.50 D at 40 cm • BI vergences at near may not compensate should suggest uncorrected hyperopia 60 59
  • 11. Binocular Vision Dysfunction Accommodative Disorders • Symptoms: aesthenopia, headaches, blurred • Symptoms: blur, vision (Binocular Vision/Visual Discomfort Dx) headache, – Associated with reading or near work aesthenopia, aesthenopia fatigue • Signs: when reading, – Phorias: Normal at distance and near difficulty changing – Reduced BI and BO vergences at distance focus from one and/or near distance to another 61 62 Accommodative Disorders Other BV Disorders • Signs • Divergence Excess – Accommodative Insufficiency: – Prevalence of ~0.5 to 4% • Reduced amplitude of accommodation – Exophoria greater at distance than near • Minimum Accommodation: 15 - (0.25) (age) – Frequently first discovered in grade school – Accommodative Infacility • Divergence Insufficiency • Failure of monocular facility testing • Expected value: 11 cpm – Very rare! – Esophoria greater at distance than near – Be careful to rule out lateral rectus palsy! 63 64 Strabismus & Amblyopia Exotropia 3-6% of the population CI, Intermittent XT @ nearTxT appropriate at all ages i llMay do out of office VT DE, Intermittent XT @ distance and achieve success! 65 66
  • 12. Accommodative Esotropia Accommodative EsotropiaFirst seen in 2-4 year oldsUncorrected hyperopia From: http://www.strabismus.org/ esotropia_eye_turns_in.ht High ACA ml 67 68 Diplopia & Head Turns/Tilts Amblyopia Paresis or paralysis? Pathological until proven otherwise Infants/Toddlers Duane’s Retraction Syndrome Young Children Busy Adults 69 70 Efficacy of Optometric Amblyopia Vision Therapy Pathological until Efficacy of vision therapy as assessed by the Anisometropia p COVD quality of life checklist. Maples WC, p proven otherwise Bither MM. Infants/Toddlers Bilateral Refractive Error The COVD-QOL can be used to measure Young Children changes in symptoms, and to objectively Strabismus (Constant) demonstrate quality of life changes that are No disease present achieved through optometric vision therapy. Busy Adults 71 72
  • 13. Efficacy of Optometric Efficacy of Optometric Vision Therapy Vision TherapyCiuffreda KJ. The scientific basis for and Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. efficacy of optometric vision therapy in Optom Vis Sci. 2005 Jul;82(7):583-95. non-strabismic accommodative and …vision therapy/orthoptics was the ii h / h i h vergence disorders. Optometry. only treatment that produced 2002;73(12):735-62 clinically significant improvements in the near point of convergence and positive fusional vergence. 73 74 Efficacy of Optometric Vision Therapy Treatment for BV DisordersA Randomized Clinical Trial of Treatments for Symptomatic Convergence Evidence Based Medicine Insufficiency in Children Mitchell Scheiman, OD, FCOVD, CITT Study ChairOffice Based Vergence/Accommodation Therapy Cotter S et al Treatment of strabismic amblyopia with al. was significantly more effective than Home Based refractive correction. Am J Ophthalmol. 2007 Jun;143(6):1060-3. Pencil Pushups, Home Based Computer Vergence/ Accommodation Therapy with PP+, and Office These results support the suggestion …that strabismic Based Placebo Therapy in improving both the amblyopia can improve and even resolve with spectacle symptoms and clinical signs associated with correction alone. symptomatic CI in children 75 76 Treatment for BV Disorders Refractive Error Myopia: Can Its Progression Be Controlled? Yi Pang, PhD, OD, Dominick M. Maino, Scheimann M et al. Randomized trial of treatment of amblyopia in OD, MEd, FAAO Guoming Zhang, MD, PhD, Fan Lu, MD, OD children aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437- 47. …. muscarinic receptor antagonists, including usca c ecepto a tago sts, c ud g Amblyopia improves with optical correction alone in about one fourth of patients aged 7 to 17 years, although most patients who atropine and pirenzepine. Bifocal and are initially treated with optical correction alone will require progressive lenses can be effective in the additional treatment for amblyopia. For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching with near visual control of myopia and have greater activities and atropine can improve visual acuity even if the amblyopia has been previously treated. For patients 13 to 17 years, effectiveness for subjects with nearpoint prescribing patching 2 to 6 hours per day with near visual activities esophoria and a high lag of accommodation. may improve visual acuity when amblyopia has not been previously treated 77 78
  • 14. New Amblyopia Treatments? Refractive Error Two-year multicenter, randomized, double-masked, placebo-controlled, parallel safety and efficacy study of Thompson B, Mansouri B, Koski L, Hess 2% pirenzepine ophthalmic gel in children with myopia. RF. Brain plasticity in the adult: R. Michael Siatkowski MD, Susan A. Cotter OD, MS . Et modulation of function in amblyopia with al. rTMS. Curr Biol. 2008 Jul 2;18(14):1067- Pirenzepine ophthalmic gel 2% was effective compared with 71. placebo in slowing the progression of myopia over a 2-year treatment period and demonstrated a clinically acceptable safety profile. ( J AAPOS 2008;12:332-339) Watch for studies on “Perceptual Learning”! 79 80 Video-GameLi RW, Ngo C, Nguyen J, Levi DM (2011)Play Induces Plasticity in the Visual Learning Related Vision ProblemsSystem of Adults with Amblyopia. PLoS Biol9(8): e1001135. doi:10.1371/journal.pbio.1001135 All vision problems affect learning, usually as a secondary contributing…..video-game play may provide factor. f timportant principles for treating New research suggests that theamblyopia, and perhaps other cortical Magnocellular pathway may show adysfunctions. direct vision link. 81 82 Learning Related Vision Problems Learning Related Vision Problems Repeatability of the VMI Supplemental Developmental Test of Visual Perception Marjean Taylor Kulp, OD, MS, FAAO and Michael J. Subitizing and Visual Counting in Children with Earley, OD, PhD, FAAO Problems in Acquiring Basic Arithmetic Skills Burkhart Fischer, Dipl. Phys., Christine Gebhardt, Dipl. Visual perceptual ability has been found to be related to academic achievement. Therefore, the screening of Phys., and Klaus Hartnegg, Dipl. Phys. h d l i l h perceptual skills in children should provide valuable information. … The VMI Supplemental Developmental Test of Visual Perception We concluded that the deficit in a basic visual capacity (VP) test 1) has been shown to be related to academic performance, 2) may contribute to the problems encountered by children has an objective scoring system and 3) can be administered and scored quickly and easily. Therefore, the VP test may have the potential to be with anomalies in acquiring basic arithmetic skills. used as a stand-alone screening test of motor-reduced visual perception. However, its repeatability as a stand-alone screening test Fischer B, Gebhardt C, Hartnegg K. Subitizing and Visual Counting in Children has not been evaluated. No consistent learning effect appeared to be with Problems in Acquiring Basic Arithmetic Skills. Optom Vis Dev present upon retest. 2008:39(1):24-29. • It give repeatable results. 83 84
  • 15. Learning Related Learning Related Vision Problems Vision ProblemsEffects of Daily Practice on Subitizing, Visual Solan H et al. M-cell deficit and reading Counting, and Basic Arithmetic Skills Burkhart disability: a preliminary study of the effects of Fischer, Dipl. Phys., Christine Gebhardt, Dipl. Phys., and Klaus Hartnegg, Dipl. Phys. temporal vision-processing therapy.Since the result of the second study of this paper shows a Optometry. 2004 Oct;75(10):640-50. transfer from improvements in subitizing to improvements of basic arithmetic skills one may This research supports the value of rendering temporal vision therapy to children conclude that the basic visual capacity of subitizing and identified as moderately reading disabled (RD). The diagnostic procedures and visual number counting contributes to the problem the dynamic therapeutic techniques discussed in this article have not been encountered by children with dyscalculia. previously used for the specific purpose of ameliorating an M-cell deficit. Improved temporal visual-processing skills and enhanced visual motionFischer B, Gebhardt C, Hartnegg K. Subitizing and Visual Counting in Children discrimination appear to have a salutary effect on magnocellular processing and with Problems in Acquiring Basic Arithmetic Skills. Optom Vis Dev reading comprehension in RD children with M-cell deficits. 2008:39(1):24-29. 85 86 Learning Related Learning Related Vision Problems Vision ProblemsSolan H et al. Is there a common linkage among reading The Effects of HTS Vision Therapy Conducted in a School Settingcomprehension, visual attention, and magnocellular on Reading Skills in Third and Fourth Grade Students David Goss,processing? J Learn Disabil. 2007 May-Jun;40(3):270-8. O.D., Ph.D., FAAO, FCOVD-A, et. al.Solan H et al. Role of visual attention in cognitive control of oculomotor A Study of the Effectiveness of Cognitive Skill Therapy Delivered inreadiness in students with reading disabilities. Learn Disabil. 2001 Mar- a Video Game Format Don Helms, O.D., and Sara M. Sawtelle, Ph.D.Apr;34(2):107-18. Training Direction-Discrimination Sensitivity Remediates a WideEye movement therapy improved eye movements Spectrum of Reading Skills Teri Lawton, Ph.D.and also resulted in significant gains in readingcomprehension. Optom Vis Dev. 2007;38(1) 87 88 Learning Related Learning Related Vision Problems Vision ProblemsVision, Visual-Information Processing, and Academic A randomized prospective masked and matchedPerformance Among Seventh-Grade Schoolchildren: A comparative study of orthoptic treatment versusMore Significant Relationship Than We Thought? Sarina conventional reading tutoring treatment for readingGoldstand, Kenneth C. Koslowe and Shula Parush American Journal of Occupational disabilities in 62 children.Therapy July/August 2005 vol. 59 no. 4 377-389 Atzmon D, Nemet P, et al.Effect of attention therapy on reading comprehension. Binocular Vision & Eye Muscle Surgery Quarterly, 8(2):p.Solan HA, Shelley-Tremblay J, Ficarra A, Silverman M, 91-106, 1993.Larson S. J Learn Disabil. 2003 Nov-Dec;36(6):556-63. 89 90
  • 16. Orthoptic treatment, to increase convergence Optometric Vision Therapy areamplitudes to 60 D, is as effective as NOT!conventional in-school reading tutoringtreatment of reading disabilities. An advantage oforthoptic treatment was that subjective reading and asthenopicsymptoms (excessive tearing, itching, burning, visual fatigue, andheadache) virtually disappeared after orthoptics. We recommendorthoptic treatment as: 1) an effective alternateprimary treatment; 2) adjunctive treatment for thosewho do not respond well to standard treatment; and3) as primary treatment in any case with asthenopicsymptoms of /or convergence inadequacy. Eye Exercisers! 91 92 Vision Therapy is…..! Treatment for BV Disorders • Treatment modalities – Lenses – Prisms – Vision therapy • Traditional therapy Brain Therapy • Computer therapy Neuro-therapy Neuro-plasticity Therapy 93 94 Lenses as Treatment Best Rx (clarity, comfort, function) Lenses as TreatmentRefractive Error Amblyopia Binocularity Interference Rx if…. Concern Concerns with Learning • Best Rx (clarity, comfort, function)Myopia >5.00D Under correct Depends >5.00D (any age) eso/Fully o child’s on c d s >3.00D @>1yr • Accommodative disorders correct exo age – Can prescribe reading only Rx or an addHyperopia >2.00D Under correct >2.50D >2.00D • Exodeviations exo/Fully correct eso – Overminusing (DE)Astigmatism >1.25D Depends >1.25D – Not usually a first choice! Give add on VAAnisometropia >1.00D Monitor >1.00D >1.00D 95 96 BV/Stereo
  • 17. Bifocals for Kids Bifocals for Kids Bifocal Seg Height Bifocal Seg Height 3-5 Years Infants/Toddlers Bottom 1/3 of Pupil Pre-schoolers Bi-sect pupil 97 98 Bifocals for Kids Bifocals for Myopia ProgressionBifocal Seg Height Gwiazda JE, Hyman L, Norton TT, Hussein ME, Marsh-Tootle W, Manny R, Wang Y, Everett D; COMET Grouup. Accommodation and related risk factors associated with myopia progression and their interaction with treatment in COMET children. Invest Ophthalmol Vis Sci 2004 Jul;45(7):2143-51. Sci. Jul;45(7):2143-51 > 5yrs ….Children with large lags of accommodation and Bottom of Pupil near esophoria …are prescribed …bifocals to improve visual performance. Results of this study suggest that such children, if myopic, may have an additional benefit of slowed progression of myopia….. 99 100 Polycarbonate Lenses Prism as Treatment • Can be used with CI, CE, DI, DE, Vertical Deviations • Prescribe the least amount of prism needed – Determine the associated phoria with a Wesson Card or Bernell Box • Fresnel Prism trial, then Rx 101 102
  • 18. Optometric Vision Therapy as Treatment Vision Therapy as Treatment• The approach of choice for CI, Fusional • Traditional therapy Vergence Dysfunctions, accommodative – Hand-eye, Vergence and Accommodative disorders, disorders and Amblyopia procedures – High chance of success with these disorders • Computer Therapy – Results are typically long lasting – Can attack hand-eye, vergence, accommodative – Often can treat these disorders using primarily and oculomotor problems (Vision information home VT with in-office check-ups processing anomalies?) 103 104 Vision Therapy for Amblyopia Period of Sensitivity • Prescribe Rx vs • Implement occlusion therapy Period of Plasticity • Active vision therapy • Monitor • Change Rx/Tx as needed 105 106 Atropine AtropinePediatric Eye Disease Investigator Group. Repka MX, Cotter SA, Beck RW, Kraker RT, The course of moderate amblyopia (20/100) Birch EE, Everett DF, Hertle RW, Holmes treated with atropine in children: JM, Quinn GE, Sala NA, Scheiman MM, experience of the amblyopia treatment Stager DR Sr, Wallace DK; A randomized trial of atropine regimens for treatment of study. moderate amblyopia in children. Am J Ophthalmol. 2003 Oct;136(4):630-9. Ophthalmology. 2004 Nov;111(11):2076- 85. 107 108
  • 19. Atropine Occlusion Therapy Age (yrs) Per Day Schedule Minimum Exam Frequency 1 4 60min periods 1 day on/1 day off WeeklyWeekend atropine provides an 2 3 30min periods 2 day on/1 day off Every 2 wks improvement in VA of a magnitude 3 3 30min periods 3 day on/1 day off Every 3 wks similar to that of the improvement 4 2 60min periods 4 day on/1 day off Every 4 wks provided by daily atropine in treating moderate amblyopia in children 3 to 7 5 2 60min periods 5 day on/1 day off Every 5 wks years old. 6 2 60min periods 6 day on/1 day off Every 6 wks 109 110 Amblyopia Therapy Active Vision Therapy What do we know about Hand-eye amblyopia? Oculomotor –MMore than d h decreased VAd – Visual-Spatial affects Accommodation – Accommodation – Hand-eye Have child “Do Stuff” – Stereopsis Interact with environment 111 112 Vision Therapy as TreatmentRoberts CJ, Adams GG.Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 Phases of TherapyHigh anisometropic amblyopia is g p y p • Monocular (HE, OM, ACC) challenging to treat. …contact • Biocular (HE, OM, ACC, Anti-suppression) lenses improved visual acuity in • Binocular (Vergence, Acc) myopic anisometropia of up to 9 • Integration/Stabilization diopters. Do it all at the same time! 113 114
  • 20. Vision Therapy as Treatment Vision Therapy as Treatment Phases of Therapy Phases of Therapy• Monocular (HE, OM, ACC) • Monocular (HE, OM, ACC)• Biocular (HE, OM, ACC, Anti-suppression) • Biocular (HE, OM, ACC, Anti-suppression)• Binocular (Vergence, Acc) • Binocular (Vergence, Acc)• Integration/Stabilization • Integration/Stabilization Do it all at the same time! Do it all at the same time! 115 116 Vision Therapy as Treatment Vision Therapy as Treatment Phases of Therapy Phases of Therapy• Monocular (HE, OM, ACC) • Monocular (HE, OM, ACC)• Biocular (HE, OM, ACC, Anti-suppression) • Biocular (HE, OM, ACC, Anti-suppression)• Binocular (Vergence, Acc) • Binocular (Vergence, Acc)• Integration/Stabilization • Integration/Stabilization Do it all at the same time! Do it all at the same time! 117 118 Traditional Therapy Procedures Traditional Therapy Procedures• Hand-Eye Procedures • Vergence procedures – mazes – Brock String – dot to dot – Lifesaver card BI and BO – cutting – Anaglyph Series (BC920, others) – coloring • Accommodative Procedures – filling in O’s – Minus lens dips – Bunt Ball – Flippers – Hart Chart 119 120
  • 21. Vergence Procedures Vergence Procedures Brock String Life Saver Cards Simple Inexpensive BO and BI d Easy Good fusion Effective Anti-suppression Inexpensive Effective Brock String 121 122 Vergence Procedures Vergence Procedures Aperture RuleFusion Cards “Flying W” Random dot targets StereoscopesBC 920, BC 50 Vectograms Eccentric Circles Anaglyph series Vectograms Aperture RuleAperture Rule 123 124 Accommodative Procedures Accommodative Procedures Rock Card Hart Chart Flippers the old standby Anti-suppression 125 126
  • 22. Vision Therapy Videos Vision Therapy Videos http://www.youtube.com/watch?v=HtzEHSie-90 http://www.youtube.com/watch?v=fX8mqtgdzgs 127 128 Vision Therapy Videos Vision Therapy Videos http://www.youtube.com/watch?v=Ui3KTZOdzbohttp://www.youtube.com/watch?v=RTy3o8DwON8 http://www.youtube.com/watch?v=wcVX684r3xQ 129 130 Computer Vision Therapy Computer Vision Therapy• Can attack vergence, accommodative, and oculomotor problems • Computer based vision therapy program• Most programs are set up to record patient’s • Patient can use at home, work, wherever performance each session they have access to computer – Removes the problem of compliance! • Trains eye movements, vergences,• Different products on the market accommodation, and perceptual skills – Home Therapy System – Computer Aided Vision Therapy 131 132
  • 23. Why use Computer Aided VT? How do you incorporate Computer Aided Vision • “Patients who cannot make a time Therapy in your program? commitment • Patient compliance problems • Diagnose the patient!!! • Insurance or Third Party Problems • Assign a therapy protocol • It’s Fun! • Computer aided VT in the office • Schedule follow-up appointments • Evaluate the patient’s progress/Follow-up 133 134 Computer Aided VT Resources Computer Aided VT ResourcesComputer Orthoptics HTS (Home Therapy System) http://www.homevisiontherapy.com/ 135 136 Computer Aided VT Resources Computer Aided VT Resources 137 138
  • 24. Computer Aided VT Resources Computer Aided VT Resources Computerized Aided Vision Therapy Gary Vogel, OD, FAAO http://www.cavt.net/software.html Available from Bernell 800-348-2225 http://www.bernell.com/ 139 140 Computerized Aided Computerized Aided Vision Therapy Vision Therapy Module 1 Track and Read Module 2: Visual Therapy Visual information processing skills Visual attention/fixation test Visual reaction time test Left-right warm-ups Directional reactions Directional questions Random targets Short term visual memory test Directional grids Tachistoscopic arrows Eye tracking test Satellite commando game 141 142 Computerized Aided Computerized Aided Vision Therapy Vision Therapy Module 2: Visual Therapy Module 2: Visual Therapy Visual Skills Therapy py Therapy Procedures py Visual attention/fixation Tracking with NumbersTic-Tac-Toe rotations Spatial Sequencing Span of recognition Random eye movementsSpatial Patters BPDQ Grids Short term visual memoryCircles, Boxes, Triangles Geo Boards Large angle eye movementsRotating patterns 143 144
  • 25. Computerized Aided Computerized Aided Vision Therapy Vision Therapy Module 2: Visual Therapy Module 2: Visual Therapy Visual Figure Ground Skills Visual Closure Skills Therapy Circles & boxes Lines & rectanglesTarget counting Character searching Closing on center Closing patternsLetter locator Dot to dot Letters/numbers dot to dotShapes Hidden patterns Closing words Tracking with sequences/words Verbal saccades Tracking with stories 145 146 Computerized Aided Vision Therapy Vision Builder Module 3: Computer VergencesJu p vergences (s g e/doub e ta gets)Jump ve ge ces (single/double targets) Smooth vergences Pursuit vergences Life saver drills Anti-suppression games 147 148 Brainware Safari Brainware Safari Helms D, Sawtelle SM. A study of the effectiveness of cognitive therapy delivered in a video game format. Optom ; ( ) Vis Dev 2007;38(1):19-26. Students in the study group showed an average of 4 years and 3 months improvement on tests of cognitive skills, compared to 4 months improvement for the control group and showed an average of 1 year and 11 months improvement on tests of achievement compared to 1 month for the control group. http://www.brainwareforyou.com/ http://www.brainwareforyou.com/ 149 150
  • 26. Conclusions VT Equipment • Easy to incorporate VT for BV disorders Use the tools into your activities discussed • Monitor the output to check for compliance and tricks! You do not need a • Remember that the key is in diagnosing patients and follow-up whole room of VT “stuff” 151 152 WWW Sites for BV/VT BV Organizations Gemstonevision.Org COVD http://www.covd.org/ OEP http://www.oepf.org// 949-250-8070 AAO BV Section http://www.aaopt.org/section/bv/index.asp 153 154 301-984-1441 BV Organizations Patient WWW SitesPAVE/Parents Active 3 D Picturesfor Vision Education http://www.vision3d.com/optical/http://www.pavevision.org/htt // ii / index.shtml#stereogram i d ht l# tNeuro-Optometric How Does Binocular Vision Work?Rehabilitation Association http://www.vision3d.com/stereo.htmlhttp://www.nora.cc/ 155 156
  • 27. Position Statement on VT Patient WWW Sites AOA, AAO, COVD many others: Position Statement on• http://www.chil dren-special- Optometric Vision Therapy needs.org/visio d / ii “The American Optometric Association n_therapy/what affirms its long standing position that _is_vision_ther optometric vision therapy is effective in the apy.html treatment of physiological, neuromuscular and perceptual dysfunctions of the vision system……..” 157 158 MainosMemos, Facebook, LinkedIn, ICO My Private Office 159 160 Social/ Professional Connections 161 162
  • 28. Questions? Contact: Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor, Pediatric/Binocular Vision Service Illinois Eye Institute/Illinois College of Optometry 3241 S. Michigan Ave. Chicago, Il. 60610 312-949-7280 voice 312-949-7668 fax Private Practice 708-867-7838dmaino@ico.edu MainosMemos.blogspot.com www.nw.optometry.net www.ico.edu