To BV or not to BV


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A course for the primary care optometrists on binocular viison

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To BV or not to BV

  1. 1. To BV or Not to BV: VT in the Primary Care Office 23rd Annual Victoria Conference Delta Ocean Pointe Resort Victoria, BC Pacific University College of Optometry July 18th-21, 2013 1 To BV or Not to BV: That is No Longer the Question, But Rather the Answer! 2 Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor, Pediatrics/Binocular Vision Illinois Eye Institute Illinois College of Optometry Chicago, Il Lyons Family Eye Care Chicago, Il 3 To BV or Not to BV: That is No Longer the Question, But Rather the Answer! • ..Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous economics, or to take arms against a sea of troubles with binocular vision and optometric vision therapy. To grunt and sweat under a weary life, But that the dread of something unknown....the undiscovered country of BV and VT whose bourn all travelers prosper, doth not puzzle the will and makes us rather bear those joys we have...than those ills of 3rd party payers that we know not of? (With apologies to The Bard). This course reviews the diagnostic and evidence-based therapeutic procedures the primary care optometrist can use to improve patient care while supporting the fiscal stability of their practice. 4 5 Executive Summary • Binocular vision in the news • 3D Vision Syndrome in the news • High incidence of BV problems • Evidence based medicine/research supports optometric vision therapy 6
  2. 2. Executive Summary • Amblyopia can be treated at any age • Learning related vision problems optometric intervention supported by research • Attention and binocular vision problems related 7 Executive Summary • Our patients are in pain • Proven examination techniques available • Proven intervention/therapy available 8 Executive Summary • The myths of OVT wrong • Expand your patient base • Be unique • Offer more 9 10/121 BV Dx & Tx in the News!! 3D In the News: Update! 11 BV Dx & Tx in the News!! 12
  3. 3. BV Dx & Tx in the News!! Sports Vision ! 13 BV Dx & Tx in the News!! 14 BV Dx & Tx in the News!! 15 BV Dx & Tx in the News!! 16 BV Dx & Tx in the News!! 10/97 17 Non-strabismic BV disorders Prevalence/Incidence • Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5% • Convergence Excess: ~6% • Accommodative disorders: 3-5% 18
  4. 4. Non-strabismic BV disorders • Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5% • 309,000,000 people in USA (2010 Census) at 5% = 15 million + 19 Non-strabismic BV disorders • Convergence Excess: ~6% • 18 million + 20/121 Non-strabismic BV disorders • Accommodative disorders: 3-5% • 15 million + 21 Non-strabismic BV disorders If any other disease had this prevalence/incidence, it would be considered an epidemic…if not a pandemic! 22 CI on TV 23 NIH NEI and CI 24
  5. 5. Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 25 Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 26 Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 27 Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 28 Screening for BV Dysfunction 20/97 29 Effectiveness of computerized oculomotor vision screening in a military population: Pilot study José E. Capó-Aponte, OD, PhD, et al. The number of warfighters affected by blast induced mild traumatic brain injury (mTBI) has increased considerably in the recent years as a consequence of the current conflicts. Oculomotor (eye movement) vision problems frequently result from mTBI; however, conventional oculomotor examinations are time-consuming and can only be performed by an eye doctor. This limits the number of military personnel that can be evaluated for oculomotor problems before and after deployment. This study showed that computerized oculomotor vision screening performed by non-eye-care providers can be an effective means to expedite the identification and management of oculomotor vision problems in patients with or without mTBI. Capó-Aponte JE, Tarbett AK, Urosevich TG, Temme LA, Sanghera NK, Kalich ME. Effectiveness of computerized oculomotor vision screening in a military population: Pilot study. J Rehabil Res Dev. 2012;49(9):1377–98. Comprehensive Eye Examination Visual Efficiency Evaluation Strab/Amblyopia Examination Vision Information Processing Assessment Special Testing: Visagraph, TOVA 20/97 PATIENT MAMAGEMENT 30/121
  6. 6. Comprehensive Eye Examination – History – VA – Refraction – BV (CT, NPC, Stereo, etc) – Eye Health 20/97 Do enough testing to meet 3rd party requirements AND determine if more testing is needed 31 Visual Efficiency Examination: Basic Tests • History (Academics, Sports, Work, Hobbies) • COVD Quality of Life Survey/CISS • Visual Acuity 20/97 32 Visual Efficiency Examination: Basic Tests • Refractive Evaluation (Objective/Subjective) 20/97 33 Visual Efficiency Examination: Basic Tests • Oculomotor –Cover Test, Hirschberg, –Kappa, Krimsky, Bruckner –EOMs –NPC (with red lens) 20/97 34 Visual Efficiency Examination: Basic Tests • Heterophoria • Vergences –Sheard’s criteria •Need twice your phoria in reserve (10 pd exophore at near needs 20 pd BO reserves) 35 Visual Efficiency Examination: Basic Tests • Accommodative Tests –Minimum amplitude = 15 - (0.25) age •So a 20 year old should have at least 10 diopters of accommodation 36
  7. 7. Visual Efficiency Examination: Basic Tests –NRA/PRA, Minus Lens Amplitudes 37 Visual Efficiency Examination: Basic Tests –Push Up/Pull Away Amplitudes, MEM –Facility 38 Basic tests • Stereopsis • Random Dot, • Stereo Fly • Less than 70 seconds of arc 39 Basic tests • Worth 4 Dot • Fixation Disparity Testing –Wesson Card, –Bernell Fixation Disparity (Associated Phoria), Disparometer 40/121 Common BV Syndromes • Convergence Insufficiency – Most common syndrome – Symptoms: aesthenopia, headaches, blur, diplopia, loss of concentration • associated with near work • often occur near the end of the day 41 Convergence Insufficiency • Signs: – An exodeviation at near • Can even be an intermittent exotropia at near – Receded NPC value • NPC larger than 10 cm – Reduced BO vergences at near • Often fail to meet Sheard’s criterion 42
  8. 8. Convergence Excess • Symptoms: Diplopia, headaches, aesthenopia – almost always near related • Signs: – Esophoria at near • Use detailed accommodative target or you may miss the esophoria – Vergences • BI vergences at near may not compensate 43 Convergence Excess • Signs –Dynamic Retinoscopy • May be the most significant test • Typically a high lag of accommodation • Lag may be +1.00 to +2.00 DS at 40 cm • Lags greater than +2.50 D at 40 cm should suggest uncorrected hyperopia 44 Fusional Vergence Dysfunction • Symptoms: aesthenopia, headaches, blurred vision (Binocular Vision/Visual Discomfort Dx) – Associated with reading or near work • Signs: – Phorias: Normal at distance and near – Reduced BI and BO vergences at distance and/or near 45 Accommodative Disorders • Symptoms: blur, headache, aesthenopia, fatigue when reading, difficulty changing focus from one distance to another 46 Accommodative Disorders • Signs –Accommodative Insufficiency: • Reduced amplitude of accommodation • Minimum Accommodation: 15 - (0.25) (age) –Accommodative Infacility • Failure of monocular facility testing • Expected value: 11 cpm 47 Other BV Disorders • Divergence Excess –Prevalence of ~0.5 to 4% –Exophoria greater at distance than near –Frequently first discovered in grade school 30/97 48
  9. 9. Other BV Disorders • Divergence Insufficiency –Very rare! –Esophoria greater at distance than near –Be careful to rule out lateral rectus palsy! 30/97 49 Strabismus & Amblyopia 3-5% of the population Tx appropriate at all ages May do out of office VT and achieve success! 50/121 Amblyopia Pathological until proven otherwise Infants/Toddlers Children Adults Amblyogenic Factors Anisometropia Bilateral Refractive Error Strabismus (Constant) 51 Amblyopia Legal Consultant Amblyopia Malpractice case was not because of missing an eye disease…But rather due to alleged inappropriate management/treatment 52 Diagnosis & Treatment for BV Disorders 53 Treatment for BV Disorders Evidence Based Medicine Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in non-strabismic accommodative and vergence disorders. Optometry. 2002;73(12):735-62 Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. Optom Vis Sci. 2005 Jul;82(7):583-95. …vision therapy/orthoptics was the only treatment that produced clinically significant improvements in the near point of convergence and positive fusional vergence. 54
  10. 10. Treatment for BV Disorders Evidence Based Medicine Scheimann M et al. Randomised clinical trial of the effectiveness of base- in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Ophthal 2005;89(10):1318-23. Base-in prism reading glasses were found to be no more effective in alleviating symptoms, improving the near point of convergence, or improving positive fusional vergence at near than placebo reading glasses for the treatment of children aged 9 to <18 years with symptomatic CI. 55 Treatment for BV Disorders Evidence Based Medicine Quaid P, Simpson T.Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls. Graefes Arch Clin Exp Ophthalmol. 2013 Jan;251(1):169-87. doi: 10.1007/s00417-012-2135-0. Epub 2012 Aug 29. The IEP group had significantly greater hyperopia compared to the control group on cycloplegic examination. Vergence facility was significantly correlated to (i) reading speed, (ii) number of eye movements made when reading, and (iii) a standardized symptom scoring system. Vergence facility was also significantly reduced in the IEP group versus controls. Significant differences in several other binocular vision related scores were also found. 56 Treatment for BV Disorders Evidence Based Medicine Solan H et al. M-cell deficit and reading disability: a preliminary study of the effects of temporal vision-processing therapy. Optometry. 2004 Oct;75(10):640- 50. This research supports the value of rendering temporal vision therapy to children identified as moderately reading disabled (RD). The diagnostic procedures and the dynamic therapeutic techniques discussed in this article have not been previously used for the specific purpose of ameliorating an M-cell deficit. Improved temporal visual-processing skills and enhanced visual motion discrimination appear to have a salutary effect on magnocellular processing and reading comprehension in RD children with M-cell deficits. 57 Treatment for BV Disorders Evidence Based Medicine Solan H et al. Is there a common linkage among reading comprehension, visual attention, and magnocellular processing? J Learn Disabil. 2007 May- Jun;40(3):270-8. Solan H et al. Role of visual attention in cognitive control of oculomotor readiness in students with reading disabilities. Learn Disabil. 2001 Mar-Apr;34(2):107-18. Eye movement therapy improved eye movements and also resulted in significant gains in reading comprehension. 58 Treatment for BV Disorders Evidence Based Medicine Cotter S et al. Treatment of strabismic amblyopia with refractive correction. Am J Ophthalmol. 2007 Jun;143(6):1060-3. These results support the suggestion from a prior study that strabismic amblyopia can improve and even resolve with spectacle correction alone. 59 Treatment for BV Disorders Evidence Based Medicine Scheimann M et al. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47. Amblyopia improves with optical correction alone in about one fourth of patients aged 7 to 17 years, although most patients who are initially treated with optical correction alone will require additional treatment for amblyopia. For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching with near visual activities and atropine can improve visual acuity even if the amblyopia has been previously treated. For patients 13 to 17 years, prescribing patching 2 to 6 hours per day with near visual activities may improve visual acuity when amblyopia has not been previously treated 60/121
  11. 11. Levi DM. Prentice award lecture 2011: removing the brakes on plasticity in the amblyopic brain. Optom Vis Sci. 2012 Jun;89(6):827-38. Video-game play induces plasticity in the visual system of adults with amblyopia. Li RW, Ngo C, Nguyen J, Levi DM. PLoS Biol. 2011 Aug;9(8):e1001135. Epub 2011 Aug 30. Prolonged perceptual learning of positional acuity in adult amblyopia: perceptual template retuning dynamics. Li RW, Klein SA, Levi DM. J Neurosci. 2008 Dec 24;28(52):14223-9. Adult Amblyopia 61 Treatment for BV Disorders • Treatment modalities – Lenses – Prisms – Vision therapy • Traditional therapy • Computer therapy 40/97 62 Lenses as Treatment Best Rx (clarity, comfort, function) Refractive Error Amblyopia Concern Binocularity Concerns Interference with Learning Rx if…. Myopia >5.00D Under correct eso/Fully correct exo Depends on child’s age >5.00D (any age) >3.00D @>1yr Hyperopia >2.00D Under correct exo/Fully correct eso >2.50D >2.00D Astigmatism >1.25D Depends on VA >1.25D Anisometropia >1.00D Monitor BV/Stereo >1.00D >1.00D 63 Lenses as Treatment • Best Rx (clarity, comfort, function) • Accommodative disorders – Can prescribe reading only Rx or an add (I never give R/O, D/O) • Exodeviations – Overminusing (DE) – May not be a first choice. Give add 64 Bifocals for Kids Bifocal Seg Height Infants/Toddlers Pre-schoolers Bi-sect pupil 65 Bifocals for Kids Bifocal Seg Height 3-5 Years Bottom 1/3 of Pupil 66
  12. 12. Bifocals for Kids Bifocal Seg Height > 5yrs Bottom of Pupil 67 Bifocals for Myopia Progression 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. 68 Bifocals for Myopia Progression PALs were effective in slowing progression in these children, with statistically significant 3-year treatment effects. The results support the COMET rationale (i.e., a role for retinal defocus in myopia progression). In clinical practice in the United States children with large lags of accommodation and near esophoria often are prescribed PALs or 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. 69 Polycarbonate/Trivex Lenses 70/121 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 71 Optometric Vision Therapy as Treatment • The approach of choice for CI, Fusional Vergence Dysfunctions, accommodative disorders, and Amblyopia – High chance of success with these disorders – Results are typically long lasting – Often can treat these disorders using primarily home VT with in-office check-ups 72
  13. 13. Vision Therapy as Treatment • Traditional therapy – Hand-eye, Vergence and Accommodative procedures • Computer Therapy – Can attack hand-eye, vergence, accommodative and oculomotor problems (Vision information processing anomalies?) 73 Vision Therapy for Amblyopia • Prescribe Rx • Implement occlusion therapy •Implement Atropine therapy • Active optometric vision therapy • Monitor • Change Rx/Tx as needed 74 Period of Sensitivity vs Period of Plasticity 75 Atropine Repka MX, Cotter SA, Beck RW, Kraker RT, Birch EE, Everett DF, Hertle RW, Holmes JM, Quinn GE, Sala NA, Scheiman MM, Stager DR Sr, Wallace DK; A randomized trial of atropine regimens for treatment of moderate amblyopia in children. Ophthalmology. 2004 Nov;111(11):2076- 85. 76 Atropine CONCLUSIONS: Weekend atropine provides an improvement in VA of a magnitude similar to that of the improvement provided by daily atropine in treating moderate amblyopia in children 3 to 7 years old. 77 Atropine Pediatric Eye Disease Investigator Group. The course of moderate amblyopia treated with atropine in children: experience of the amblyopia treatment study. Am J Ophthalmol. 2003 Oct;136(4):630-9. 78
  14. 14. Atropine A beneficial effect of atropine is present throughout the age range of 3 years old to younger than 7 years old, and with an acuity range of 20/40 to 20/100. A shift in near fixation to the amblyopic eye is not essential for atropine to be effective in all cases. Sound eye acuity should be monitored when a plano spectacle lens is prescribed for the sound eye to augment the treatment effect of atropine. 79 Occlusion Therapy Age (yrs) Per Day Schedule Minimum Exam Frequency 1 4 60min periods 1 day on/1 day off Weekly 2 3 30min periods 2 day on/1 day off Every 2 wks 3 3 30min periods 3 day on/1 day off Every 3 wks 4 2 60min periods 4 day on/1 day off Every 4 wks 5 2 60min periods 5 day on/1 day off Every 5 wks 6 2 60min periods 6 day on/1 day off Every 6 wks 80/121 Amblyopia Therapy What do we know about amblyopia? – More than decreased VA – Visual-Spatial affects – Accommodation – Hand-eye – Stereopsis 81 Active Vision Therapy Hand-eye Oculomotor Accommodation Have child “Do Stuff” Interact with environment 60/97 82 Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 CONCLUSIONS: High anisometropic amblyopia is challenging to treat. In our study contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres. 83 Vision Therapy as Treatment Phases of Therapy • Monocular (HE, OM, ACC) • Biocular (HE, OM, ACC, Anti-suppression) • Binocular (Vergence, Acc) • Integration/Stabilization Do it all at the same time! 84
  15. 15. Vision Therapy as Treatment Phases of Therapy • Monocular (HE, OM, ACC) • Biocular (HE, OM, ACC, Anti-suppression) • Binocular (Vergence, Acc) • Integration/Stabilization Do it all at the same time! 85 Vision Therapy as Treatment Phases of Therapy • Monocular (HE, OM, ACC) • Biocular (HE, OM, ACC, Anti-suppression) • Binocular (Vergence, Acc) • Integration/Stabilization Do it all at the same time! 86 Vision Therapy as Treatment Phases of Therapy • Monocular (HE, OM, ACC) • Biocular (HE, OM, ACC, Anti-suppression) • Binocular (Vergence, Acc) • Integration/Stabilization Do it all at the same time! 87 Vision Therapy as Treatment Phases of Therapy • Monocular (HE, OM, ACC) • Biocular (HE, OM, ACC, Anti-suppression) • Binocular (Vergence, Acc) • Integration/Stabilization Do it all at the same time! 88 Traditional Therapy Procedures • Hand-Eye Procedures – mazes – dot to dot – cutting – coloring – filling in O’s 89 Traditional Therapy Procedures • Vergence procedures – Brock String – Lifesaver card – Anaglyph Series (BC920, others) • Accommodative Procedures – Minus lens dips – Flippers – Hart Chart 90
  16. 16. Vergence Procedures Brock String Simple Inexpensive Easy Effective 91 Vergence Procedures Life Saver Cards BO and BI Good fusion Anti-suppression Inexpensive Effective 70/97 92 Vergence Procedures Fusion Cards Random dot targets BC 920, BC 50 Anaglyph series 93 Vergence Procedures Aperture Rule “Flying W” Stereoscopes 94 Accommodative Procedures Rock Card Flippers Anti-suppression 95 Accommodative Procedures Hart Chart the old standby 96
  17. 17. Computer Vision Therapy • Can attack vergence, accommodative, and oculomotor problems • Most programs are set up to record patient’s performance each session – Removes the problem of compliance! • Different products on the market – Home Therapy System – Computer Aided Vision Therapy – Psychological Software Services 97 Computer Vision Therapy • Patient can use at home, work, wherever they have access to computer • Trains eye movements, vergences, accommodation, and perceptual skills 98 Why use Computer Aided VT? • “I’d like to do VT in my practice, but...” • Patients who cannot afford office VT • Patients who cannot make a time commitment for office VT • Patient compliance problems • Insurance or Third Party Problems 99 How do you incorporate Computer Aided Vision Therapy in your practice ? • Diagnose the patient!!! • Assign a therapy protocol • Computer aided VT in the office • Schedule follow-up appointments • Evaluate the patient’s progress/Follow-up 100 Computer Aided VT Resources Neuroscience Center of Indianapolis http://www.neuro science.cnter.c om/ 101 .html Soft Tools Computer Aided VT Resources Computer Orthoptics HTS (Home Therapy System) 80/97 102
  18. 18. Computer Aided VT Resources Computerized Aided Vision Therapy Gary Vogel, OD, FAAO Available from Bernell 800-348-2225 103 Brainware Safari 104 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. 105 Conclusions • Easy way to incorporate VT for BV disorders into your practice • Monitor the output to check for compliance and tricks! • Remember that the key is in diagnosing patients and follow-up 106 VT Equipment Use the tools discussed You do not need a whole room of VT “stuff” 85/97 107 WWW Sites for BV/VT Gemstonevision. Org 108
  19. 19. BV Organizations COVD OEP 949-250-8070 AAO BV Section ons/bvppo/aaobvp.html 301-984-1441 109 BV Organizations PAVE/Parents Active for Vision Education Neuro-Optometric Rehabilitation Association 110 Patient WWW Sites 3 D Pictures index.shtml#stereogram How Does Binocular Vision Work? 111 Patient WWW Sites • http://www.chil dren-special- n_therapy/what _is_vision_ther apy.html 90/97 112 Position Statement on VT AOA, AAO, COVD many others: Position Statement on Optometric Vision Therapy “The American Optometric Association affirms its long standing position that optometric vision therapy is effective in the treatment of physiological, neuromuscular and perceptual dysfunctions of the vision system……..” 113 Practice Management Myths VT is Too Expensive! You Can’t Make Money Doing VT! Which is it? Can’t have it both ways! 114
  20. 20. Practice Management First Comprehensive Examination Then Visual Efficiency Strab/Amblyopia Follow-up 115 Practice Management All BV Disorders are a Medical Condition CI, CE, DI, DE, Pursuit/Saccade Dysfunction 116 Practice Management Accommodative disorders tend to be refractive Accommodative insufficiency, excess, infacility, instability, etc 95/97 117 Practice Management Visual Discomfort is a medical diagnosis 118 119 All Ages Can Benefit…. More Patients Better Patient Care Evidenced Based Do it! 120
  21. 21. 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 773-935-2020 121