Diagnosing Learning Related Vision Problems


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

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Diagnosing Learning Related Vision Problems

  1. 1. Diagnosing and Treating Learning Related Vision Problems<br />Dominick M. Maino, OD, MEd, FAAO, FCOVD-A<br />Professor<br />Illinois Eye Institute<br />Illinois College of Optometry<br />Private Practice<br />Harwood Heights, Il.<br />
  2. 2. Diagnosing and Treating Learning Related Vision Problems<br />What do Doctors do (or should do) to diagnose LRVP?<br />Where’s the research?<br />What Therapy Procedures Should I Use?<br />What’s New?<br />
  3. 3. 3<br />BV Dx & Tx in the News!!<br />
  4. 4. 4<br />
  5. 5. 5<br />
  6. 6. 6<br />3 D Movie Stars…Can’t See 3D!<br />
  7. 7. 7<br />3-D TV and Movies Look to Attract Viewers But Not Everyone Can 'See' What All the Hype is About <br />
  8. 8. 8<br />Healthbeat Report: The 3-D Dilemma<br />
  9. 9. 9<br />3 D Classroom!<br />…Studies have shown that the measurable<br />educational benefits of presenting teaching<br />materials in 3D are significant, generating a threefold improvement in comprehension and retention over the more traditional non - 3D style of presentation. And students respond well to the immersive and engaging qualities of the 3D effect … <br />AOA/3D@Home<br />www.3Dhealth.org<br />
  10. 10. 10<br />Non-strabismic BV disorders<br />Prevalence <br />Prevalence of General Dysfunctions in Binocular Vision . Montés-Micó Robert. Annals of Ophthalmology, Volume 33, Number 3, September 2001 , pp. 205-208(4). (Spain)<br />…in 1679 subjects aged 18 to 38 years. …. A high prevalence of binocular vision dysfunctions was found. … 56.2% presented symptoms of binocular dysfunctions, 61.4% with accommodation disorders and 38.6% vergence disorders. Accommodation insufficiency was most prevalent among those with symptoms (11.4%). …<br />
  11. 11. 11<br />BV disorders<br />Prevalence <br />Pickwell's Binocular Vision Anomalies  By Bruce J. W. Evans, David Pickwell <br />Between 1 in 5 to 1 in 10 individuals have BV problems. 30-60 million people<br />
  12. 12. 12<br />BV disorders<br />Prevalence <br />Prevalence and risk factors for common vision problems in children (in the UK)<br />…for 7825 seven-year-old children. 2.3% had manifest strabismus, 3.6% had …amblyopia….<br />
  13. 13. 13<br />Non-strabismic BV disorders<br />Prevalence <br />General binocular disorders: prevalence in a clinic population. Ophthalmic & Physiological Optics. 21(1):70-74, January 2001.Lara, Francisco 2; Cacho, Pilar 1; Garcia, Angel 1; Megias, Ramon 2 <br />….We examined 265 symptomatic patients …., 59 patients (22.3%) had some form of accommodative or binocular dysfunction …. The frequency of binocular dysfunctions was 12.9%, and 9.4% for accommodative anomalies. Convergence excess (4.5%) was more prevalent than convergence insufficiency (0.8%) and accommodative excess (6.4%) more prevalent than accommodative insufficiency (3%).<br />
  14. 14. 14<br />BV disorders<br />Prevalence: Additional Articles <br />Prevalence of general binocular dysfunctions in a population of university students.<br />32.3% of the subjects showed general <br />binocular dysfunctions<br />
  15. 15. 15<br />BV disorders<br />Prevalence: Additional Articles <br />Stereoacuity levels and vision problems <br />in children from 7 to 11 years<br />…prevalence of defective stereoscopic vision was found to be between 2.1 and 3.2 per cent<br />
  16. 16. 16<br />BV disorders<br />Prevalence: Additional Articles<br />Prevalence of amblyopia in <br />ametropias in a clinical set-up <br />…Out of 970 ametropic eye patients a total of 56 (5.97%) <br />patients have amblyopia….<br />
  17. 17. 17<br />Non-strabismic BV disorders<br />Prevalence <br />Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5%<br />Convergence Excess: ~6%<br />Accommodative disorders: 3-5%<br />AOA: Care of the Patient with Accommodative and Vergence Dysfunction<br />http://www.aoa.org/documents/CPG-18.pdf<br />
  18. 18. 18<br />What Does the Doctor Do to Diagnose Learning Related Vision Problems?<br />
  19. 19. 19<br />Can We Measure Symptoms<br />Test-retest reliability of the college of optometrists in vision development quality of life outcomes assessment.MAPLES W. C. , et al.<br />The COVD Quality of Life Outcomes Assessment is a reliable tool to measure changes in symptoms on the basis of optometric intervention-specifically, vision therapy <br />
  20. 20. 20<br />Can We Measure Symptoms<br />Evaluating Changes in Quality of Life After Vision Therapy Using the COVD Quality of Life Outcomes Assessment Kelly M. Daugherty, OD, et. al. <br />The COVD – QOL Questionnaire in a socially at-risk population of youthWillard B. Bleything, OD, MS, FAAO, FCOVD, Sandra L. Landis, OD, FCOVD <br />
  21. 21. 21<br />Can We Measure Symptoms<br />Validity of the convergence insufficiency symptom survey: a confirmatory study.<br />Rouse M, Borsting E, Mitchell GL, et al.<br />…The CISS continues to be a valid instrument for quantifying symptoms in 9 to <18-year-old children…<br />
  22. 22. 22<br />Subjective Complaints of Patients with BV Disorders<br />Blur<br />Headache<br />Aesthenopia<br />Diplopia<br />These complaints are usually associated with near work<br />
  23. 23. 23<br />Subjective Complaints of Patients with BV Disorders<br />Blur<br />Headache<br />Aesthenopia<br />Diplopia<br />These complaints are usually associated with near work<br />
  24. 24. 24<br />Subjective Complaints of Patients with BV Disorders<br />Blur<br />Headache<br />Aesthenopia<br />Diplopia<br />These complaints are usually associated with near work<br />
  25. 25. 25<br />Subjective Complaints of Patients with BV Disorders<br />Blur<br />Headache<br />Aesthenopia<br />Diplopia<br />These complaints are usually associated with near work<br />
  26. 26. 26<br />Examination Sequence<br />Comprehensive Eye/Vision Examination<br />Visual Efficiency Examination<br />Vision Information Processing Examination<br />
  27. 27. 27<br />Examination Sequence<br />Comprehensive Eye/Vision Examination<br />History <br />Visual Acuity <br />Oculomotor/Entrance Tests<br />Refraction <br />Eye Health<br />
  28. 28. 28<br />Examination Sequence<br />Visual Efficiency Evaluation<br />HX <br />(Symptoms related to near work, school, sports, BV dysfucntions, etc.)<br />VA<br />Oculomotor System<br />Sensory Fusion System<br />Motor Fusion/Vergence System<br />Accommodative System<br />
  29. 29. 29<br />Visual Efficiency Examination<br />
  30. 30. 30<br />Visual Efficiency Examination<br />
  31. 31. 31<br />Examination Sequence<br />Vision Information Processing Examination<br />Laterality/Directionality<br />Visual Information Processing Non-motor<br />Visual Information Processing Motor<br />Oculomotor<br />Auditory Information Processing<br />Misc.<br />
  32. 32. 32<br />VIP<br />
  33. 33. 33<br />VIP<br />
  34. 34. 34<br />Master Problem List<br />
  35. 35. 35<br />Master Problem List<br />
  36. 36. 36<br />Visual Efficiency Examination: Basic Tests<br />History<br />Must be geared towards the child or adult with likely binocular vision dysfunction, learning related vision problems or work/recreational related functional vision anomalies.<br />
  37. 37. 37<br />Visual Efficiency Examination: Basic Tests<br />Visual acuity<br />May find reduced acuity at <br />near or complaints of <br />blur at near (intermittent <br />problems)<br />
  38. 38. 38<br />Visual Efficiency Examination: Basic Tests<br />Refraction<br />Control Lens<br />
  39. 39. 39<br />Visual Efficiency Examination: Basic Tests<br />Oculomotor System<br />Pursuits, Saccades<br />Developmental Eye Movement Test DEM<br />Visagraph/Readalyzer<br />
  40. 40. 40<br />Visual Efficiency Examination: Basic Tests<br />Developmental Eye Movement Test DEM<br />J . TASSINARI<br />Developmental Eye Movement Test: reliability and symptomatology .  <br />Journal of the American Optometric Association ,2005; <br />Volume 76 , <br />Issue 7 , Pages 387 - 399<br />
  41. 41. 41<br />Visual Efficiency Examination: Basic Tests<br />Cover test<br />Distance and near<br />Repeat during the exam to see if fatigue changes your result<br />
  42. 42. 42<br />Visual Efficiency Examination: Basic Tests<br />Nearpoint of convergence<br />Repeat several times<br />See what happens with fatique<br />Red lens sensitive for CI<br />A prospective study of different test targets for<br />the near point of convergence<br />Yi Pang, Helen Gabriel, Kelly A. Frantz and Faheemah Saeed<br />
  43. 43. 43<br />Visual Efficiency Examination: Basic Tests<br />Heterophoria<br />In Phoropter<br />Prism Bar<br />Risley Prism/Madox Rod<br />
  44. 44. 44<br />Other tests<br />2 Degree Fusion<br />Suppression<br />Worth 4 Dot<br />
  45. 45. 45<br />Basic tests<br />Stereopsis<br />Look for reduced steropsis<br />Less than 70 seconds of arc<br />
  46. 46. 43<br />Basic tests<br />Accommodative amplitude<br />Either push-up, push away methods or minus lens method<br />Minimum amplitude = 15 - (0.25) age<br />So a 20 year old should have at least 10 diopters of accommodation<br />The minus lens method exhibited the best repeatability... <br />Repeatability intra-examiner and agreement in amplitude of accommodation measurements<br />Antona B, Barra F, Barrio A, Gonzalez E, Sanchez I.<br />
  47. 47. 47<br />Basic tests<br />Accommodative facility<br />Perform monocularly and binocularly <br />with suppression control (+/-2.00)<br />~10 cycles per minute is diagnostic<br />For children with reading problems: Binocular accommodative facility values were significantly lower (p < 0.05) in the poor readers (4.9 cpm +/- 3.1) than controls (6.3 cpm +/- 2.9) <br />Accommodative function in school children with reading difficulties. Palomo-Alvarez C, Puell MC.<br />
  48. 48. 48<br />Basic tests<br />NRA<br />Negative Relative Accommodation<br />PRA<br />Positive Relative Accommodation<br />
  49. 49. 49<br />Basic tests<br />Vergences<br />Use either prism bars or Risley prisms<br />Sheard’s criteria<br />Need twice your phoria in reserve<br />Example: a 10 pd exophore at near needs 20 pd BO reserves<br />
  50. 50. 50<br />Other Tests<br />Dynamic Retinoscopy<br />Monocular Estimation Method<br />Expected Values: <br />+0.50 to +0.75 D<br />
  51. 51. 51<br />Other Tests<br />Fixation Disparity Testing<br />Wesson Card<br />Bernell Fixation Disparity (Associated Phoria)<br />Disparometer<br />
  52. 52. 52<br />Other Tests<br />Fixation Disparity Testing<br />Wesson Card<br />Bernell Fixation Disparity (Associated Phoria)<br />Disparometer<br />
  53. 53. 53<br />Other Tests<br />Fixation Disparity Testing<br />Wesson Card<br />Bernell Fixation Disparity (Associated Phoria)<br />Disparometer<br />
  54. 54. 54<br />Other Tests<br />
  55. 55. 55<br />
  56. 56. 56<br />
  57. 57. 57<br />Common BV Syndromes<br />Convergence Insufficiency<br />Most common syndrome<br />Symptoms: aesthenopia, headaches, blur, diplopia, loss of concentration<br />associated with near work<br />often occur near the end of the day<br />
  58. 58. 58<br />Convergence Insufficiency<br />Signs:<br />An exodeviation at near<br />Can even be an intermittent exotropia at near<br />Receded NPC value<br />NPC larger than 10 cm<br />Reduced BO vergences at near<br />Often fail to meet Sheard’s criterion<br />
  59. 59. 59<br />Convergence Excess<br />Symptoms: Diplopia, headaches, aesthenopia<br />almost always near related<br />Signs:<br />Esophoria at near<br />Use detailed accommodative target or you may miss the esophoria<br />Vergences<br />BI vergences at near may not compensate<br />
  60. 60. 60<br />Convergence Excess<br />Signs<br />Dynamic Retinoscopy<br />May be the most significant test<br />Typically a high lag of accommodation<br />Lag may be +1.00 to +2.00 DS at 40 cm<br />Lags greater than +2.50 D at 40 cm should suggest uncorrected hyperopia<br />
  61. 61. 61<br />Binocular Vision Dysfunction<br />Symptoms: aesthenopia, headaches, blurred vision (Binocular Vision/Visual Discomfort Dx)<br />Associated with reading or near work<br />Signs: <br />Phorias: Normal at distance and near<br />Reduced BI and BO vergences at distance and/or near<br />
  62. 62. 62<br />Accommodative Disorders<br />Symptoms: blur, headache, aesthenopia, fatigue when reading, difficulty changing focus from one distance to another<br />
  63. 63. 63<br />Accommodative Disorders<br />Signs<br />Accommodative Insufficiency: <br />Reduced amplitude of accommodation<br />Minimum Accommodation: 15 - (0.25) (age)<br />Accommodative Infacility<br />Failure of monocular facility testing<br />Expected value: 11 cpm<br />
  64. 64. 64<br />Other BV Disorders<br />Divergence Excess<br />Prevalence of ~0.5 to 4%<br />Exophoria greater at distance than near<br />Frequently first discovered in grade school<br />Divergence Insufficiency<br />Very rare!<br />Esophoria greater at distance than near<br />Be careful to rule out lateral rectus palsy!<br />
  65. 65. 65<br />Strabismus & Amblyopia<br />3-6% of the population<br />Tx appropriate at all ages<br />May do out of office VT <br />and achieve success!<br />
  66. 66. 66<br />Exotropia<br />CI, Intermittent XT @ near<br />DE, Intermittent XT @ distance<br />
  67. 67. 67<br />Accommodative Esotropia<br />First seen in 2-4 year olds<br />Uncorrected hyperopia<br />High ACA<br />
  68. 68. 68<br />Accommodative Esotropia<br />From: http://www.strabismus.org/esotropia_eye_turns_in.html<br />
  69. 69. 69<br />Diplopia & Head Turns/Tilts<br />Paresis or paralysis?<br />Duane’s Retraction Syndrome<br />
  70. 70. 70<br />Amblyopia<br />Pathological until proven otherwise<br />Infants/Toddlers<br />Young Children<br />Busy Adults<br />
  71. 71. 71<br />Amblyopia<br />Pathological until proven otherwise<br />Infants/Toddlers<br />Young Children<br />Busy Adults<br />Anisometropia<br />Bilateral Refractive Error<br />Strabismus (Constant)<br />No disease present<br />
  72. 72. 72<br />Efficacy of Optometric Vision Therapy<br />Efficacy of vision therapy as assessed by the COVD quality of life checklist. Maples WC, Bither M.<br />The COVD-QOL can be used to measure changes in symptoms, and to objectively demonstrate quality of life changes that are achieved through optometric vision therapy.<br />
  73. 73. 73<br />Efficacy of Optometric Vision Therapy<br />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 <br />
  74. 74. 74<br />Efficacy of Optometric Vision Therapy<br />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.<br />…vision therapy/orthoptics was the only treatment that produced clinically significant improvements in the near point of convergence and positive fusional vergence.<br />
  75. 75. 75<br />Efficacy of Optometric Vision Therapy<br />A Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children Mitchell Scheiman, OD, FCOVD, CITT Study Chair<br />Office Based Vergence/Accommodation Therapy was significantly more effectivethan Home Based Pencil Pushups, Home Based Computer Vergence/ Accommodation Therapy with PP+, and Office Based Placebo Therapy in improving both the symptoms and clinical signs associated with symptomatic CI in children<br />
  76. 76. 76<br />Treatment for BV Disorders<br />Evidence Based Medicine<br />Cotter S et al. Treatment of strabismic amblyopia with refractive correction. Am J Ophthalmol. 2007 Jun;143(6):1060-3. <br />These results support the suggestion …that strabismic amblyopia can improve and even resolve with spectacle correction alone.<br />
  77. 77. 77<br />Treatment for BV Disorders<br />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.<br />Amblyopiaimproveswith 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<br />
  78. 78. 78<br />Refractive Error<br />Myopia: Can Its Progression Be Controlled? Yi Pang, PhD, OD, Dominick M. Maino, OD, MEd, FAAO GuomingZhang, MD, PhD, Fan Lu, MD, OD<br />…. muscarinic receptor antagonists, including atropine and pirenzepine. Bifocal and progressive lenses can be effective in the control of myopia and have greater effectiveness for subjects with nearpointesophoria and a high lag of accommodation.<br />
  79. 79. 79<br />Refractive Error<br />Two-year multicenter, randomized, double-masked, placebo-controlled, parallel safety and efficacy study of 2% pirenzepine  ophthalmic gel in children with  myopia. R. Michael Siatkowski MD, Susan A. Cotter OD, MS . Et al.<br />Pirenzepine ophthalmic gel 2% was effective compared with 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)<br />
  80. 80. 80<br />New Amblyopia Treatments?<br />Thompson B, Mansouri B, Koski L, Hess RF.Brain plasticity in the adult: modulation of function in amblyopia with rTMS. Curr Biol. 2008 Jul 2;18(14):1067-71.<br />Watch for studies on “Perceptual Learning”!<br />
  81. 81. 81<br />Li RW, Ngo C, Nguyen J, Levi DM (2011) Video-Game Play Induces Plasticity in the Visual System of Adults with Amblyopia. PLoS Biol 9(8): e1001135. doi:10.1371/journal.pbio.1001135<br />…..video-game play may provide important principles for treating amblyopia, and perhaps other cortical dysfunctions.<br />
  82. 82. 82<br />Learning Related Vision Problems<br />All vision problems affect learning, usually as a secondary contributing factor. <br />New research suggests that the Magnocellular pathway may show a direct vision link.<br />
  83. 83. 83<br />Learning Related Vision Problems<br />Repeatability of the VMI Supplemental Developmental Test of Visual PerceptionMarjean Taylor Kulp, OD, MS, FAAO and Michael J. Earley, OD, PhD, FAAO<br />Visual perceptual ability has been found to be related to academic achievement. Therefore, the screening of perceptual skills in children should provide valuable information. … The VMI Supplemental Developmental Test of Visual Perception (VP) test 1) has been shown to be related to academic performance, 2) 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 used as a stand-alone screening test of motor-reduced visual perception. However, its repeatability as a stand-alone screening test has not been evaluated. No consistent learning effect appeared to be present upon retest. <br /> It give repeatable results. <br />
  84. 84. 84<br />Learning Related Vision Problems<br />Subitizing and Visual Counting in Children with Problems in Acquiring Basic Arithmetic SkillsBurkhart Fischer, Dipl. Phys., Christine Gebhardt, Dipl. Phys., and Klaus Hartnegg, Dipl. Phys. <br />We concluded that the deficit in a basic visual capacity may contribute to the problems encountered by children with anomalies in acquiring basic arithmetic skills. <br />Fischer B, Gebhardt C, Hartnegg K. Subitizing and Visual Counting in Children with Problems in Acquiring Basic Arithmetic Skills. Optom Vis Dev 2008:39(1):24-29.<br />
  85. 85. 85<br />Learning Related Vision Problems<br />Effects of Daily Practice on Subitizing, Visual Counting, and Basic Arithmetic SkillsBurkhart Fischer, Dipl. Phys., Christine Gebhardt, Dipl. Phys., and Klaus Hartnegg, Dipl. Phys.<br />Since the result of the second study of this paper shows a transfer from improvements in subitizing to improvements of basic arithmetic skills one may conclude that the basic visual capacity of subitizing and visual number counting contributes to the problem encountered by children with dyscalculia. <br />Fischer B,Gebhardt C, Hartnegg K. Subitizing and Visual Counting in Children with Problems in Acquiring Basic Arithmetic Skills. Optom Vis Dev 2008:39(1):24-29.<br />
  86. 86. 86<br />Learning Related Vision Problems<br />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. <br />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.<br />
  87. 87. 87<br />Learning Related Vision Problems<br />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. <br />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.<br />Eye movement therapy improved eye movements and also resulted in significant gains in reading comprehension. <br />
  88. 88. 88<br />Learning Related Vision Problems<br />The Effects of HTS Vision Therapy Conducted in a School Setting on Reading Skills in Third and Fourth Grade Students David Goss, O.D., Ph.D., FAAO, FCOVD-A, et. al.A Study of the Effectiveness of Cognitive Skill Therapy Delivered in a Video Game Format Don Helms, O.D., and Sara M. Sawtelle, Ph.D. Training Direction-Discrimination Sensitivity Remediates a Wide Spectrum of Reading Skills Teri Lawton, Ph.D.<br />Optom Vis Dev. 2007;38(1)<br />
  89. 89. 89<br />Learning Related Vision Problems<br />Vision, Visual-Information Processing, and Academic Performance Among Seventh-Grade Schoolchildren: A More Significant Relationship Than We Thought? Sarina Goldstand, Kenneth C. Koslowe and Shula ParushAmerican Journal of Occupational Therapy July/August 2005 vol. 59 no. 4 377-389 <br />Effect of attention therapy on reading comprehension.<br />Solan HA, Shelley-Tremblay J, Ficarra A, Silverman M, Larson S. J Learn Disabil. 2003 Nov-Dec;36(6):556-63.<br />
  90. 90. 90<br />Learning Related Vision Problems<br />A randomized prospective masked and matched comparative study of orthoptic treatment versus conventional reading tutoring treatment for reading disabilities in 62 children. <br />Atzmon D, Nemet P, et al.<br />Binocular Vision & Eye Muscle Surgery Quarterly, 8(2):p. 91-106, 1993.<br />
  91. 91. 91<br />Orthoptic treatment, to increase convergence amplitudes to 60 D, is as effective as conventional in-school reading tutoring treatment of reading disabilities. An advantage of orthoptic treatment was that subjective reading and asthenopic symptoms (excessive tearing, itching, burning, visual fatigue, and headache) virtually disappeared after orthoptics. We recommend orthoptic treatment as: 1) an effective alternate primary treatment; 2) adjunctive treatment for those who do not respond well to standard treatment; and 3) as primary treatment in any case with asthenopic symptoms of /or convergence inadequacy. <br />
  92. 92. 92<br />Optometric Vision Therapy are NOT!<br />Eye Exercisers! <br />
  93. 93. 93<br />Vision Therapy is…..!<br />Brain Therapy<br />Neuro-therapy<br />Neuro-plasticity Therapy<br />
  94. 94. 94<br />Treatment for BV Disorders<br />Treatment modalities<br />Lenses<br />Prisms<br />Vision therapy<br />Traditional therapy<br />Computer therapy<br />
  95. 95. 95<br />Lenses as Treatment<br />Best Rx (clarity, comfort, function)<br />
  96. 96. 96<br />Lenses as Treatment<br />Best Rx (clarity, comfort, function)<br />Accommodative disorders<br />Can prescribe reading only Rx or an add<br />Exodeviations <br />Overminusing (DE)<br />Not usually a first choice! Give add<br />
  97. 97. 97<br />Bifocals for Kids<br />Bifocal Seg Height<br />Infants/Toddlers<br />Pre-schoolers<br />Bi-sect pupil<br />
  98. 98. 98<br />Bifocals for Kids<br />Bifocal Seg Height<br />3-5 Years<br />Bottom 1/3 of Pupil<br />
  99. 99. 99<br />Bifocals for Kids<br />Bifocal Seg Height<br />> 5yrs<br />Bottom of Pupil<br />
  100. 100. 100<br />Bifocals for Myopia Progression<br />Gwiazda JE, Hyman L, Norton TT, Hussein ME, Marsh-Tootle W, Manny R, Wang Y, Everett D; COMET Grouup.<br />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. <br />….Children with large lags of accommodation and 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…..<br />
  101. 101. 101<br />Polycarbonate Lenses<br />You Must Rx....<br />Polycarbonate lenses<br />For All Children !<br />
  102. 102. 102<br />Prism as Treatment<br />Can be used with CI, CE, DI, DE, Vertical Deviations<br />Prescribe the least amount of prism needed<br />Determine the associated phoria with a Wesson Card or Bernell Box<br />Fresnel Prism trial, then Rx<br />
  103. 103. 103<br />Optometric Vision Therapy as Treatment<br />The approach of choice for CI, Fusional Vergence Dysfunctions, accommodative disorders, and Amblyopia<br />High chance of success with these disorders<br />Results are typically long lasting<br />Often can treat these disorders using primarily home VT with in-office check-ups<br />
  104. 104. 104<br />Vision Therapy as Treatment<br />Traditional therapy<br />Hand-eye, Vergence and Accommodative procedures<br />Computer Therapy<br />Can attack hand-eye, vergence, accommodative and oculomotor problems (Vision information processing anomalies?)<br />
  105. 105. 105<br />Vision Therapy for Amblyopia<br /><ul><li>Prescribe Rx
  106. 106. Implement occlusion therapy
  107. 107. Active vision therapy
  108. 108. Monitor
  109. 109. Change Rx/Tx as needed</li></li></ul><li>106<br />Period of SensitivityvsPeriod of Plasticity<br />
  110. 110. 107<br />Atropine<br />Pediatric Eye Disease Investigator Group. The course of moderate amblyopia (20/100) treated with atropine in children: experience of the amblyopia treatment study.Am J Ophthalmol. 2003 Oct;136(4):630-9. <br />
  111. 111. 108<br />Atropine<br />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. <br />
  112. 112. 109<br />Atropine<br />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.<br />
  113. 113. 110<br />Occlusion Therapy<br />
  114. 114. 111<br />Amblyopia Therapy<br />What do we know about amblyopia?<br />More than decreased VA<br />Visual-Spatial affects<br />Accommodation<br />Hand-eye<br />Stereopsis<br />
  115. 115. 112<br />Active Vision Therapy<br />Hand-eye<br />Oculomotor<br />Accommodation<br />Have child “Do Stuff”<br />Interact with environment<br />
  116. 116. 113<br />Roberts CJ, Adams GG.Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 <br />High anisometropic amblyopia is challenging to treat. …contact lenses improved visual acuity in myopic anisometropia of up to 9 diopters.<br />
  117. 117. 114<br />Vision Therapy as Treatment<br />Phases of Therapy<br />Monocular (HE, OM, ACC)<br />Biocular (HE, OM, ACC, Anti-suppression)<br />Binocular (Vergence, Acc)<br />Integration/Stabilization<br /> Do it all at the same time!<br />
  118. 118. 115<br />Vision Therapy as Treatment<br />Phases of Therapy<br />Monocular (HE, OM, ACC)<br />Biocular (HE, OM, ACC, Anti-suppression)<br />Binocular (Vergence, Acc)<br />Integration/Stabilization<br /> Do it all at the same time!<br />
  119. 119. 116<br />Vision Therapy as Treatment<br />Phases of Therapy<br />Monocular (HE, OM, ACC)<br />Biocular (HE, OM, ACC, Anti-suppression)<br />Binocular (Vergence, Acc)<br />Integration/Stabilization<br /> Do it all at the same time!<br />
  120. 120. 117<br />Vision Therapy as Treatment<br />Phases of Therapy<br />Monocular (HE, OM, ACC)<br />Biocular (HE, OM, ACC, Anti-suppression)<br />Binocular (Vergence, Acc)<br />Integration/Stabilization<br /> Do it all at the same time!<br />
  121. 121. 118<br />Vision Therapy as Treatment<br />Phases of Therapy<br />Monocular (HE, OM, ACC)<br />Biocular (HE, OM, ACC, Anti-suppression)<br />Binocular (Vergence, Acc)<br />Integration/Stabilization<br />Do it all at the same time!<br />
  122. 122. 119<br />Traditional Therapy Procedures<br />Hand-Eye Procedures<br />mazes<br />dot to dot<br />cutting<br />coloring<br />filling in O’s<br />Bunt Ball<br />
  123. 123. 120<br />Traditional Therapy Procedures<br />Vergence procedures<br />Brock String<br />Lifesaver card BI and BO <br />Anaglyph Series (BC920, others)<br />Accommodative Procedures<br />Minus lens dips<br />Flippers<br />Hart Chart<br />
  124. 124. 121<br />Vergence Procedures<br />Brock String<br />Brock String <br />Simple<br />Inexpensive<br />Easy<br />Effective<br />
  125. 125. 122<br />Vergence Procedures<br />Life Saver Cards<br />BO and BI<br />Good fusion<br />Anti-suppression<br />Inexpensive<br />Effective<br />
  126. 126. 123<br />Vergence Procedures<br />Eccentric Circles<br />Aperture Rule<br />Fusion Cards<br />Random dot targets<br />BC 920, BC 50<br />Anaglyph series<br />Aperture Rule<br />
  127. 127. 124<br />Vergence Procedures<br />Vectograms<br />Aperture Rule<br />“Flying W”<br />Stereoscopes<br />Vectograms<br />
  128. 128. 125<br />Accommodative Procedures<br />Rock Card<br />Flippers<br />Anti-suppression<br />
  129. 129. 126<br />Accommodative Procedures<br />Hart Chart<br />the old standby<br />
  130. 130. 127<br />Vision Therapy Videos<br />http://www.youtube.com/watch?v=HtzEHSie-90<br />
  131. 131. 128<br />Vision Therapy Videos<br />http://www.youtube.com/watch?v=fX8mqtgdzgs<br />
  132. 132. 129<br />Vision Therapy Videos<br />http://www.youtube.com/watch?v=RTy3o8DwON8<br />
  133. 133. 130<br />Vision Therapy Videos<br />http://www.youtube.com/watch?v=Ui3KTZOdzbo<br />http://www.youtube.com/watch?v=wcVX684r3xQ<br />
  134. 134. 131<br />Computer Vision Therapy<br />Can attack vergence, accommodative, and oculomotor problems<br />Most programs are set up to record patient’s performance each session<br />Removes the problem of compliance!<br />Different products on the market<br />Home Therapy System<br />Computer Aided Vision Therapy<br />
  135. 135. 132<br />Computer Vision Therapy<br />Computer based vision therapy program<br />Patient can use at home, work, wherever they have access to computer<br />Trains eye movements, vergences, accommodation, and perceptual skills<br />
  136. 136. 133<br />Why use Computer Aided VT?<br />“Patients who cannot make a time commitment <br />Patient compliance problems<br />Insurance or Third Party Problems<br />It’s Fun!<br />
  137. 137. 134<br />How do you incorporate Computer Aided Vision Therapy in your program?<br />Diagnose the patient!!!<br />Assign a therapy protocol <br />Computer aided VT in the office<br />Schedule follow-up appointments<br />Evaluate the patient’s progress/Follow-up<br />
  138. 138. 135<br />Computer Aided VT Resources<br />Computer Orthoptics HTS (Home Therapy System)<br />http://www.homevisiontherapy.com/<br />
  139. 139. 136<br />Computer Aided VT Resources<br />
  140. 140. 137<br />Computer Aided VT Resources<br />
  141. 141. 138<br />Computer Aided VT Resources<br />
  142. 142. 139<br />Computer Aided VT Resources<br />
  143. 143. 140<br />Computer Aided VT Resources<br />Computerized Aided Vision Therapy<br />Gary Vogel, OD, FAAO<br />http://www.cavt.net/software.html<br /> Available from Bernell 800-348-2225 http://www.bernell.com/<br />
  144. 144. 141<br />Computerized Aided Vision Therapy<br />Module 1 Track and Read <br />Visual attention/fixation test<br />Visual reaction time test<br />Short term visual memory test<br />Eye tracking test<br />
  145. 145. 142<br />Computerized Aided Vision Therapy<br />Module 2: Visual Therapy<br />Visual information processing skills<br />Left-right warm-ups Directional reactions<br />Directional questions Random targets<br />Directional grids Tachistoscopic arrows<br />Satellite commando game<br />
  146. 146. 143<br />Computerized Aided Vision Therapy<br />Module 2: Visual Therapy<br />Visual Skills Therapy<br />Tic-Tac-Toe rotations Spatial Sequencing<br />Spatial Patters BPDQ Grids<br />Circles, Boxes, Triangles Geo Boards<br />Rotating patterns<br />
  147. 147. 144<br />Computerized Aided Vision Therapy<br />Module 2: Visual Therapy<br />Therapy Procedures<br />Visual attention/fixation Tracking with Numbers<br />Span of recognition Random eye movements<br />Short term visual memory <br />Large angle eye movements<br />
  148. 148. 145<br />Computerized Aided Vision Therapy<br />Module 2: Visual Therapy<br />Visual Figure Ground Skills<br />Target counting Character searching<br />Letter locator Dot to dot <br />Shapes Hidden patterns<br />
  149. 149. 146<br />Computerized Aided Vision Therapy<br />Module 2: Visual Therapy<br />Visual Closure Skills Therapy<br />Circles & boxes Lines & rectangles<br />Closing on center Closing patterns<br />Letters/numbers dot to dot<br />Closing words Tracking with sequences/words<br />Verbal saccades Tracking with stories<br />
  150. 150. 147<br />Computerized Aided Vision Therapy<br />Module 3: Computer Vergences<br />Jump vergences (single/double targets)<br />Smooth vergences Pursuit vergences<br />Life saver drills<br />Anti-suppression games<br />
  151. 151. 148<br />Vision Builder<br />
  152. 152. 149<br />Brainware Safari<br />http://www.brainwareforyou.com/<br />
  153. 153. 150<br />Brainware Safari<br />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.<br />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.<br />http://www.brainwareforyou.com/<br />
  154. 154. 151<br />Conclusions<br />Easy to incorporate VT for BV disorders into your activities<br />Monitor the output to check for compliance and tricks!<br />Remember that the key is in diagnosing patients and follow-up<br />
  155. 155. 152<br />VT Equipment<br />Use the tools discussed<br />You do not need a whole room of VT “stuff”<br />
  156. 156. 153<br />WWW Sites for BV/VT<br />Gemstonevision.Org<br />
  157. 157. 154<br />BV Organizations<br />COVD http://www.covd.org/<br />OEP http://www.oepf.org//<br />949-250-8070 <br />AAO BV Sectionhttp://www.aaopt.org/section/bv/index.asp<br />301-984-1441<br />
  158. 158. 155<br />BV Organizations<br />PAVE/Parents Active <br />for Vision Education<br />http://www.pavevision.org/<br />Neuro-Optometric<br />Rehabilitation Association<br />http://www.nora.cc/<br />
  159. 159. 156<br />Patient WWW Sites<br />3 D Pictures<br />http://www.vision3d.com/optical/<br />index.shtml#stereogram<br />How Does Binocular Vision Work?<br />http://www.vision3d.com/stereo.html<br />
  160. 160. 157<br />Patient WWW Sites<br />http://www.children-special-needs.org/vision_therapy/what_is_vision_therapy.html<br />
  161. 161. 158<br />Position Statement on VT<br />AOA, AAO, COVD many others:<br />Position Statement on <br />Optometric Vision Therapy<br />“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……..”<br />
  162. 162. 159<br />My Private Office<br />
  163. 163. 160<br />MainosMemos, Facebook, LinkedIn, ICO<br />
  164. 164. 161<br />
  165. 165. 162<br />Social/ProfessionalConnections<br />
  166. 166. Questions? Contact:<br />Dominick M. Maino, OD, MEd, FAAO, FCOVD-A<br />Professor, Pediatric/Binocular Vision Service<br />Illinois Eye Institute/Illinois College of Optometry<br />3241 S. Michigan Ave. Chicago, Il. 60610<br />312-949-7280 voice 312-949-7668 fax<br />Private Practice 708-867-7838<br />dmaino@ico.eduMainosMemos.blogspot.com<br />www.nw.optometry.net www.ico.edu<br />