To BV or Not to BV


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To BV or Not to BV

  1. 1. To BV or Not to BV: That is No Longer the Question,But Rather the Answer!
  2. 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. 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. 4. 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
  5. 5. Executive Summary• Amblyopia can be treated at any age• Learning related vision problems optometric intervention supported by research• Attention and binocular vision problems related
  6. 6. Executive Summary• Our patients are in pain• Proven examination techniques available• Proven intervention/therapy available
  7. 7. Executive Summary• The myths of OVT wrong• Expand your patient base• Be unique• Offer more
  8. 8. BV Dx & Tx in the News!!
  9. 9. BV Dx & Tx in the News!!
  10. 10. BV Dx & Tx in the News!!
  11. 11. BV Dx & Tx in the News!!10/97
  12. 12. 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%
  13. 13. 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 +
  14. 14. Non-strabismic BV disorders• Convergence Excess: ~6%• 18 million +
  15. 15. Non-strabismic BV disorders• Accommodative disorders: 3-5%• 15 million +
  16. 16. Non-strabismic BV disorders• If any other disease had this prevalence, it would be considered an epidemic…if not a pandemic!
  17. 17. Subjective Complaints of Patients with BV Disorders• Blur• Headache• Aesthenopia• Diplopia• These complaints are usually associated with near work
  18. 18. Subjective Complaints of Patients with BV Disorders• Blur• Headache• Aesthenopia• Diplopia• These complaints are usually associated with near work
  19. 19. Subjective Complaints of Patients with BV Disorders• Blur• Headache• Aesthenopia• Diplopia• These complaints are usually associated with near work
  20. 20. Subjective Complaints of Patients with BV Disorders• Blur• Headache• Aesthenopia• Diplopia• These complaints are usually associated with near work
  21. 21. Visual Efficiency Examination: Basic Tests • History • Visual Acuity20/97
  22. 22. Visual Efficiency Examination: Basic Tests • Refractive Evaluation (Objective/Subjective)20/97
  23. 23. Visual Efficiency Examination: Basic Tests • Oculomotor – Cover Test, Hirschberg, – Kappa, Krimsky, Bruckner – EOMs – NPC (with red lens)20/97
  24. 24. 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)
  25. 25. 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
  26. 26. Visual Efficiency Examination: Basic Tests–NRA/PRA, Minus Lens Amplitudes
  27. 27. Visual Efficiency Examination: Basic Tests–Push Up/Pull Away Amplitudes, MEM–Facility
  28. 28. Basic tests• Stereopsis• Random Dot,• Stereo Fly • Less than 70 seconds of arc
  29. 29. Basic tests• Worth 4 Dot• Fixation Disparity Testing – Wesson Card, – Bernell Fixation Disparity (Associated Phoria), Disparometer
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Accommodative Disorders• Symptoms: blur, headache, aesthenopia, fatigue when reading, difficulty changing focus from one distance to another
  36. 36. 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
  37. 37. Other BV Disorders • Divergence Excess – Prevalence of ~0.5 to 4% – Exophoria greater at distance than near – Frequently first discovered in grade school30/97
  38. 38. Other BV Disorders • Divergence Insufficiency – Very rare! – Esophoria greater at distance than near – Be careful to rule out lateral rectus palsy!30/97
  39. 39. Strabismus & Amblyopia 3-5% of the populationTx appropriate at all agesMay do out of office VT and achieve success!
  40. 40. AmblyopiaPathological until Amblyogenic proven otherwise FactorsInfants/Toddlers AnisometropiaYoung Children Bilateral Refractive Error Busy Adults Strabismus (Constant)
  41. 41. Amblyopia Legal Consultant AmblyopiaMalpractice case was not because of missing an eye disease…But rather due to alleged inappropriate management/treatment
  42. 42. Treatment for BV DisordersEvidence Based MedicineCiuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in non-strabismic accommodative and vergence disorders. Optometry. 2002;73(12):735-62Scheimann 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.
  43. 43. Treatment for BV DisordersEvidence Based MedicineScheimann 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.
  44. 44. Treatment for BV Disorders Evidence Based MedicineSolan H et al. M-cell deficit and reading disability: a preliminary study of theeffects of temporal vision-processing therapy. Optometry. 2004 Oct;75(10):640-50.This research supports the value of rendering temporal vision therapy to childrenidentified as moderately reading disabled (RD). The diagnostic procedures andthe dynamic therapeutic techniques discussed in this article have not beenpreviously used for the specific purpose of ameliorating an M-cell deficit.Improved temporal visual-processing skills and enhanced visual motiondiscrimination appear to have a salutary effect on magnocellular processing andreading comprehension in RD children with M-cell deficits.
  45. 45. Treatment for BV Disorders Evidence Based MedicineSolan H et al. Is there a common linkage among reading comprehension, visualattention, 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 instudents with reading disabilities. Learn Disabil. 2001 Mar-Apr;34(2):107-18.Eye movement therapy improved eye movementsand also resulted in significant gains in readingcomprehension.
  46. 46. Treatment for BV Disorders Evidence Based MedicineCotter S et al. Treatment of strabismic amblyopia withrefractive correction. Am J Ophthalmol. 2007Jun;143(6):1060-3.These results support the suggestion from a prior study thatstrabismic amblyopia can improve and even resolve withspectacle correction alone.
  47. 47. Treatment for BV Disorders Evidence Based MedicineScheimann M et al. Randomized trial of treatment of amblyopia in childrenaged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47.Amblyopia improves with optical correction alone in about one fourth ofpatients aged 7 to 17 years, although most patients who are initially treatedwith optical correction alone will require additional treatment for amblyopia.For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patchingwith near visual activities and atropine can improve visual acuity even if theamblyopia has been previously treated. For patients 13 to 17 years,prescribing patching 2 to 6 hours per day with near visual activities mayimprove visual acuity when amblyopia has not been previously treated
  48. 48. Adult AmblyopiaLevi DM. Prentice award lecture 2011: removing thebrakes on plasticity in the amblyopic brain.Optom Vis Sci. 2012 Jun;89(6):827-38.Video-game play induces plasticity in the visual system ofadults 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 adultamblyopia: perceptual template retuning dynamics.Li RW, Klein SA, Levi DM.J Neurosci. 2008 Dec 24;28(52):14223-9.
  49. 49. Treatment for BV Disorders • Treatment modalities – Lenses – Prisms – Vision therapy • Traditional therapy • Computer therapy40/97
  50. 50. Lenses as Treatment Best Rx (clarity, comfort, function)Refractive Error Amblyopia Binocularity Interference Rx if…. Concern Concerns with LearningMyopia >5.00D Under correct Depends >5.00D (any age) eso/Fully on child’s >3.00D @>1yr correct exo ageHyperopia >2.00D Under correct >2.50D >2.00D exo/Fully correct esoAstigmatism >1.25D Depends >1.25D on VAAnisometropia >1.00D Monitor >1.00D >1.00D BV/Stereo
  51. 51. Lenses as Treatment• Best Rx (clarity, comfort, function)• Accommodative disorders – Can prescribe reading only Rx or an add• Exodeviations – Overminusing (DE) – Not usually a first choice! Give add
  52. 52. Bifocals for KidsBifocal Seg Height Infants/Toddlers Pre-schoolers Bi-sect pupil
  53. 53. Bifocals for KidsBifocal Seg Height 3-5 YearsBottom 1/3 of Pupil
  54. 54. Bifocals for KidsBifocal Seg Height > 5yrs Bottom of Pupil
  55. 55. Bifocals for Myopia ProgressionGwiazda 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.
  56. 56. Bifocals for Myopia ProgressionPALs 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.
  57. 57. Polycarbonate/Trivex Lenses
  58. 58. 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
  59. 59. 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-ups50/97
  60. 60. 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?)
  61. 61. Vision Therapy for Amblyopia • Prescribe Rx • Implement occlusion therapy • Active optometric vision therapy • Monitor • Change Rx/Tx as needed
  62. 62. Period of Sensitivity vsPeriod of Plasticity
  63. 63. AtropineRepka 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.
  64. 64. AtropineCONCLUSIONS: 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.
  65. 65. AtropinePediatric 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.
  66. 66. AtropineA 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.
  67. 67. Occlusion TherapyAge (yrs) Per Day Schedule Minimum Exam Frequency1 4 60min periods 1 day on/1 day off Weekly2 3 30min periods 2 day on/1 day off Every 2 wks3 3 30min periods 3 day on/1 day off Every 3 wks4 2 60min periods 4 day on/1 day off Every 4 wks5 2 60min periods 5 day on/1 day off Every 5 wks6 2 60min periods 6 day on/1 day off Every 6 wks
  68. 68. Amblyopia TherapyWhat do we know about amblyopia? – More than decreased VA – Visual-Spatial affects – Accommodation – Hand-eye – Stereopsis
  69. 69. Active Vision Therapy Hand-eye Oculomotor Accommodation Have child “Do Stuff” Interact with environment60/97
  70. 70. Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 High anisometropic amblyopia isCONCLUSIONS: challenging to treat. In our study contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres.
  71. 71. 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!
  72. 72. 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!
  73. 73. 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!
  74. 74. 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!
  75. 75. 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!
  76. 76. Traditional Therapy Procedures• Hand-Eye Procedures – mazes – dot to dot – cutting – coloring – filling in O’s
  77. 77. Traditional Therapy Procedures• Vergence procedures – Brock String – Lifesaver card – Anaglyph Series (BC920, others)• Accommodative Procedures – Minus lens dips – Flippers – Hart Chart
  78. 78. Vergence ProceduresBrock String Simple Inexpensive Easy Effective
  79. 79. Vergence Procedures Life Saver Cards BO and BI Good fusion Anti-suppression Inexpensive Effective70/97
  80. 80. Vergence Procedures Fusion Cards Random dot targetsBC 920, BC 50Anaglyph series
  81. 81. Vergence ProceduresAperture Rule “Flying W”Stereoscopes
  82. 82. Accommodative Procedures Rock Card FlippersAnti-suppression
  83. 83. Accommodative ProceduresHart Chart the old standby
  84. 84. 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
  85. 85. Computer Vision Therapy• Patient can use at home, work, wherever they have access to computer• Trains eye movements, vergences, accommodation, and perceptual skills
  86. 86. 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
  87. 87. 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
  88. 88. Computer Aided VT Resources Neuroscience Center of Indianapolis
  89. 89. Computer Aided VT Resources Computer Orthoptics HTS (Home Therapy System)
  90. 90. Computer Aided VT Resources Computerized Aided Vision Therapy Gary Vogel, OD, FAAO Available from Bernell 800-348-2225
  91. 91. Brainware Safari
  92. 92. Brainware SafariHelms 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.
  93. 93. 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
  94. 94. VT Equipment Use the tools discussed You do not need a whole room of VT “stuff”85/97
  95. 95. WWW Sites for BV/VT Gemstonevision. Org
  96. 96. BV OrganizationsCOVD 949-250-8070AAO BV Section 301-984-1441
  97. 97. BV OrganizationsPAVE/Parents Activefor Vision Education Association
  98. 98. Patient WWW Sites3 D Pictures Does Binocular Vision Work?
  99. 99. Patient WWW Sites • http://www.chil dren-special- n_therapy/what _is_vision_ther apy.html90/97
  100. 100. 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 thetreatment of physiological, neuromuscular and perceptual dysfunctions of the vision system……..”
  101. 101. Practice Management Myths VT is Too Expensive!You Can’t Make Money Doing VT!Which is it? Can’t have it both ways!
  102. 102. Practice Management FirstComprehensive Examination Then Visual Efficiency Strab/Amblyopia Follow-up
  103. 103. Practice Management All BV Disorders are a Medical ConditionCI, CE, DI, DE, Pursuit/Saccade Dysfunction
  104. 104. Practice Management Accommodative disorders tend to be refractiveAccommodative insufficiency, excess, infacility, instability, etc 95/97
  105. 105. Practice Management Visual Discomfortis a medical diagnosis
  106. 106. All Ages Can Benefit…. More Patients Better Patient Care Evidenced Based Do it!
  107. 107. Questions? Contact:Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor, Pediatric/Binocular Vision ServiceIllinois 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