To BV or not To BV: That's No Longer the Question, but the Answer
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor, Pediatrics/Binocular Vision To BV or Not to BV: Illinois Eye Institute Illinois College of Optometry That is No Longer the Chicago, Il Question, Q i Lyons Family Eye Care Chicago, Il But Rather the Answer! 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. Executive Summary Executive Summary• Binocular vision in the news • Amblyopia can be treated at any age• 3D Vision Syndrome in the news y • Learning related vision p g problems• High incidence of BV problems optometric intervention supported by• Evidence based medicine/research research supports optometric vision therapy • Attention and binocular vision problems related
Executive Summary Executive Summary• Our patients are in pain • The myths of OVT wrong• Proven examination techniques • Expand your patient base available • Be unique• Proven intervention/therapy • Offer more available BV Dx & Tx in the News!! BV Dx & Tx in the News!! BV Dx & Tx in the News!! BV Dx & Tx in the News!! 10/97
Non-strabismic BV disorders Non-strabismic BV disorders Prevalence/Incidence • Convergence Insufficiency: 1.3% to 37% of• Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5% the population; most report 3-5%• Convergence Excess: ~6% • 309,000,000 people in USA (2010 Census)• Accommodative disorders: 3-5% at 5% = 15 million + Non-strabismic BV disorders Non-strabismic BV disorders• Convergence Excess: ~6% 6% • Accommodative disorders: 3-5% 3 5%• 18 million + • 15 million + Subjective Complaints of Non-strabismic BV disorders Patients with BV Disorders• If any other disease had this • Blur • Headache prevalence, it would be l i ld b • Aesthenopia considered an epidemic…if • Diplopia not a pandemic! • These complaints are usually associated with near work
Subjective Complaints of Subjective Complaints of Patients with BV Disorders Patients with BV Disorders • Blur • Blur • Headache • Headache H d h • Aesthenopia • Aesthenopia • Diplopia • Diplopia • These complaints are usually • These complaints are usually associated with near work associated with near work Subjective Complaints of Visual Efficiency Examination: Patients with BV Disorders Basic Tests • Blur • History • Headache H d h • Aesthenopia • Visual Acuity i lA i • Diplopia • These complaints are usually associated with near work 20/97 Visual Efficiency Examination: Visual Efficiency Examination: Basic Tests Basic Tests • Oculomotor – Cover Test, Hirschberg, • R f ti E l ti Refractive Evaluation – Kappa, Krimsky, Bruckner (Objective/Subjective) – EOMs – NPC (with red lens)20/97 20/97
Visual Efficiency Examination: Visual Efficiency Examination: Basic Tests Basic Tests• Heterophoria • Accommodative Tests• Vergences –Minimum amplitude = Minimum –Sheard’s criteria 15 - (0.25) age • Need twice your phoria in reserve (10 pd exophore at near needs • So a 20 year old should have at 20 pd BO reserves) least 10 diopters of accommodation Visual Efficiency Examination: Visual Efficiency Examination: Basic Tests Basic Tests –NRA/PRA, –Push Up/Pull Away Minus Lens Amplitudes, A lit d MEM Amplitudes –Facility Basic tests Basic tests• Stereopsis • Worth 4 Dot• Random Dot,, • Fi ti Disparity Testing Fixation Di it T ti• Stereo Fly – Wesson Card, • Less than – Bernell Fixation 70 seconds of arc Disparity (Associated Phoria), Disparometer
Common BV Syndromes Convergence Insufficiency• Convergence Insufficiency • Signs: – Most common syndrome – An exodeviation at near – Symptoms: aesthenopia, • C even be an i Can b intermittent exotropia at near i i headaches, blur, diplopia, loss of – Receded NPC value concentration • NPC larger than 10 cm • associated with near work – Reduced BO vergences at near • often occur near the end of the day • Often fail to meet Sheard’s criterion Convergence Excess Convergence Excess • Signs • Symptoms: Diplopia, headaches, aesthenopia – Dynamic Retinoscopy – almost always near related • May be the most significant test • Signs: • Typically a high lag of accommodation – Esophoria at near • Lag may be +1.00 to +2.00 DS at 40 • Use detailed accommodative target or you may miss cm the esophoria – Vergences • Lags greater than +2.50 D at 40 cm • BI vergences at near may not compensate should suggest uncorrected hyperopia Fusional Vergence Dysfunction Accommodative Disorders • Symptoms: aesthenopia, headaches, • Symptoms: blur, blurred vision (Binocular Vision/Visual headache, Discomfort Dx) aesthenopia, aesthenopia fatigue when reading, – Associated with reading or near work difficulty changing • Signs: focus from one – Phorias: Normal at distance and near distance to another – Reduced BI and BO vergences at distance and/or near
Accommodative Disorders Other BV Disorders • Signs – Accommodative Insufficiency: • Divergence Excess • Reduced amplitude of accommodation p – Prevalence of ~0.5 to 4% • Minimum Accommodation: – Exophoria greater at distance than 15 - (0.25) (age) near – Accommodative Infacility – Frequently first discovered in grade • Failure of monocular facility testing school • Expected value: 11 cpm 30/97 Other BV Disorders Strabismus & Amblyopia • Divergence Insufficiency 3-5% of the population – Very rare! – Esophoria greater at distance than near Tx T appropriate at all ages i ll – Be careful to rule out lateral rectus May do out of office VT palsy! and achieve success!30/97 Amblyopia Amblyopia Legal Consultant Pathological until Amblyogenic p proven otherwise Factors Amblyopia Infants/Toddlers Anisometropia Malpractice case was not because of missing Young Children Bilateral Refractive Error an eye disease…But rather due to alleged inappropriate management/treatment Busy Adults Strabismus (Constant)
Treatment for BV Disorders Treatment for BV Disorders Evidence Based Medicine Evidence Based Medicine Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in Scheimann M et al. Randomised clinical trial of the effectiveness of base- non-strabismic non strabismic accommodative and vergence disorders. Optometry. disorders Optometry in i i prism reading glasses versus placebo reading glasses for di l l b di l f 2002;73(12):735-62 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 Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. alleviating symptoms, improving the near point of convergence, or Optom Vis Sci. 2005 Jul;82(7):583-95. improving positive fusional vergence at near than placebo reading …vision therapy/orthoptics was the only treatment that produced clinically glasses for the treatment of children aged 9 to <18 years with significant improvements in the near point of convergence and positive symptomatic CI. fusional vergence. Treatment for BV Disorders Treatment for BV Disorders Evidence Based Medicine Evidence Based MedicineSolan H et al. M-cell deficit and reading disability: a preliminary study of the Solan H et al. Is there a common linkage among reading comprehension, visualeffects of temporal vision processing therapy. Optometry. 2004 Oct;75(10):640- vision-processing Oct;75(10):640 attention, and magnocellular processing? J Learn Disabil. 2007 May-50. Jun;40(3):270-8. Solan H et al. Role of visual attention in cognitive control of oculomotor readiness inThis research supports the value of rendering temporal vision therapy to children students with reading disabilities. Learn Disabil. 2001 Mar-Apr;34(2):107-18.identified 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. Eye movement therapy improved eye movementsImproved temporal visual-processing skills and enhanced visual motiondiscrimination appear to have a salutary effect on magnocellular processing and and also resulted in significant gains in readingreading comprehension in RD children with M-cell deficits. comprehension. Treatment for BV Disorders Treatment for BV Disorders Evidence Based Medicine Evidence Based Medicine Scheimann M et al. Randomized trial of treatment of amblyopia in childrenCotter S et al Treatment of strabismic amblyopia with al. aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47. g y p p ( )refractive correction. Am J Ophthalmol. 2007 Amblyopia improves with optical correction alone in about one fourth ofJun;143(6):1060-3. 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 patchingThese results support the suggestion from a prior study that with near visual activities and atropine can improve visual acuity even if thestrabismic amblyopia can improve and even resolve with amblyopia has been previously treated. For patients 13 to 17 years,spectacle correction alone. prescribing patching 2 to 6 hours per day with near visual activities may improve visual acuity when amblyopia has not been previously treated
Adult Amblyopia Levi DM. Prentice award lecture 2011: removing the DM. Treatment for BV Disorders brakes on plasticity in the amblyopic brain. Optom Vis Sci. 2012 Jun;89(6):827-38. Jun;89(6):827- • Treatment modalities Video- Video-game play induces plasticity in the visual system of – Lenses adults with amblyopia. amblyopia. – Prisms Li RW, Ngo C, Nguyen J, Levi DM. PLoS Biol. 2011 Aug;9(8):e1001135. Epub 2011 Aug 30. – Vision therapy • Traditional therapy Prolonged perceptual learning of positional acuity in adult • Computer therapy amblyopia: amblyopia: perceptual template retuning dynamics. Li RW, Klein SA, Levi DM. J Neurosci. 2008 Dec 24;28(52):14223-9. Neurosci. 24;28(52):14223- 40/97 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,Myopia >5.00D Under correct Depends >5.00D (any age) function) eso/Fully o child’s on c d s >3.00D @>1yr correct exo • Accommodative disorders age – Can prescribe reading only Rx or anHyperopia >2.00D Under correct >2.50D >2.00D exo/Fully add correct eso • ExodeviationsAstigmatism >1.25D Depends >1.25D – Overminusing (DE) on VA – Not usually a first choice! Give addAnisometropia >1.00D Monitor >1.00D >1.00D BV/Stereo 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
Bifocals for Kids Bifocals for Myopia Progression Bifocal Seg Height Gwiazda JE, Hyman L, Norton TT, Hussein ME, Marsh-Tootle W, Manny R, Wang Y, Everett D; COMET Grouup. > 5yrs Accommodation and related risk factors associated with myopia progression and their interaction with Bottom of Pupil treatment in COMET children. Invest Ophthalmol Vis Sci. 2004 Jul;45(7):2143- 51. Bifocals for Myopia Progression Polycarbonate/Trivex LensesPALs were effective in slowing progression in these children, with statistically significant 3-year treatment effects The results support the COMET effects. 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. Optometric Vision Therapy Prism as Treatment as Treatment • Can be used with CI, CE, DI, DE, Vertical • The approach of choice for CI, Fusional Deviations Vergence Dysfunctions, accommodative • Prescribe the least amount of prism needed disorders, disorders and Amblyopia – Determine the associated phoria with a Wesson – High chance of success with these disorders Card or Bernell Box – Results are typically long lasting • Fresnel Prism trial, then Rx – Often can treat these disorders using primarily home VT with in-office check-ups 50/97
Vision Therapy for Amblyopia Vision Therapy as Treatment • Traditional therapy • Prescribe Rx – Hand-eye, Vergence and Accommodative • Implement occlusion therapy procedures • Active optometric vision therapy • Computer Therapy – Can attack hand-eye, vergence, accommodative • Monitor and oculomotor problems (Vision information processing anomalies?) • Change Rx/Tx as needed Period of Sensitivity Atropine vs Repka MX, Cotter SA, Beck RW, Kraker RT, Birch EE, Everett DF, Hertle RW, Holmes Period of Plasticity 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. Atropine Atropine Pediatric Eye Disease Investigator Group. The course of moderate amblyopia treated withCONCLUSIONS: Weekend atropine atropine in children: experience of the provides an i id improvement in VA of a ti f magnitude similar to that of the amblyopia treatment study. improvement provided by daily Am J Ophthalmol. 2003 Oct;136(4):630-9. atropine in treating moderate amblyopia in children 3 to 7 years old.
Atropine Occlusion Therapy Age (yrs) Per Day Schedule Minimum Exam FrequencyA beneficial effect of atropine is present 1 4 60min periods 1 day on/1 day off Weekly throughout the age range of 3 years old to g g g y 2 3 30min periods 2 day on/1 day off Every 2 wks younger than 7 years old, and with an acuity range of 20/40 to 20/100. A shift in near 3 3 30min periods 3 day on/1 day off Every 3 wks 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 4 2 60min periods 4 day on/1 day off Every 4 wks spectacle lens is prescribed for the sound eye to augment the treatment effect of atropine. 2 60min periods 5 day on/1 day off 5 Every 5 wks 6 2 60min periods 6 day on/1 day off Every 6 wks Amblyopia Therapy Active Vision Therapy What do we know about amblyopia? Hand-eye – More than decreased VA Oculomotor – Visual-Spatial affects Accommodation – Accommodation – Hand-eye – Stereopsis Have child “Do Stuff” Interact with environment 60/97 Vision Therapy as Treatment Phases of TherapyRoberts CJ, Adams GG. Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 • Monocular (HE, OM, ACC) High anisometropic amblyopia isCONCLUSIONS: • Biocular (HE, OM, ACC, Anti-suppression) challenging to treat. In our study contact • Binocular (Vergence, Acc) lenses improved visual acuity in myopic anisometropia of up to 9 dioptres. • Integration/Stabilization Do it all at the same time!
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! 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! Traditional Therapy Procedures Traditional Therapy Procedures• Hand-Eye Procedures • Vergence procedures – mazes – Brock String – dot to dot – Lifesaver card – cutting – Anaglyph Series (BC920, others) – coloring • Accommodative Procedures – filling in O’s – Minus lens dips – Flippers – Hart Chart
Vergence Procedures Vergence ProceduresBrock String Life Saver Cards Simple BO and BI d Inexpensive Good fusion Easy Anti-suppression Effective Inexpensive Effective 70/97 Vergence Procedures Vergence Procedures Fusion Cards Aperture Rule Random dot targets “Flying W”BC 920, BC 50Anaglyph series Stereoscopes Accommodative Procedures Accommodative Procedures Rock Card Hart Chart Flippers the old standbyAnti-suppression
Computer Vision Therapy Computer Vision Therapy• Can attack vergence, accommodative, and oculomotor problems • Patient can use at home, work,• Most programs are set up to record patient’s wherever they have access to performance each session computer – Removes the problem of compliance! • Trains eye movements,• Different products on the market vergences, accommodation, – Home Therapy System and perceptual skills – Computer Aided Vision Therapy – Psychological Software Services Why use Computer Aided VT? How do you incorporate Computer Aided Vision• “I’d like to do VT in my practice, but...” Therapy in your practice ?• Patients who cannot afford office VT• P ti t who cannot make a time Patients h t k ti • Diagnose the patient!!! commitment for office VT • Assign a therapy protocol• Patient compliance problems • Computer aided VT in the office• Insurance or Third Party Problems • Schedule follow-up appointments • Evaluate the patient’s progress/Follow-upComputer Aided VT Resources Computer Aided VT Resources Neuroscience Center of Indianapolis Computer Orthoptics http://www.neuroscience.cnter.com/ HTS (Home Therapy System) http://www.homevisiontherapy.com/ 80/97
Computer Aided VT Resources Brainware Safari Computerized Aided Vision Therapy Gary Vogel, OD, FAAO Available from Bernell 800-348-2225 http://www.brainwareforyou.com/ http://www.bernell.com/ Brainware Safari Conclusions • Easy way to incorporate VT for BV Helms D, Sawtelle SM. A study of the effectiveness of disorders into your practice cognitive therapy delivered in a video game format. Optom ; ( ) Vis Dev 2007;38(1):19-26. • Monitor the output to check for compliance Students in the study group showed an average of 4 years and 3 and tricks! months improvement on tests of cognitive skills, compared to 4 months improvement for the control group and showed an • Remember that the key is in diagnosing average of 1 year and 11 months improvement on tests of patients and follow-up achievement compared to 1 month for the control group. http://www.brainwareforyou.com/ VT Equipment WWW Sites for BV/VT Use the tools Gemstonevision. discussed Org You do not need a whole room of VT “stuff”85/97
BV Organizations BV OrganizationsCOVD http://www.covd.org/ PAVE/Parents ActiveOEP http://www.oep.org/ for Vision Education http://www.pave-eye.com/ htt // / 949-250-8070 Neuro-Optometric Rehabilitation AssociationAAO BV Section http://www.noravc.com/http://www.aaopt.org/sections/bvppo/aaobvp.html 301-984-1441 Patient WWW Sites Patient WWW Sites3 D Pictures • http://www.chilhttp://www.vision3d.com/optical/ dren-special-index.shtml#stereogrami d ht l# t needs.org/visio d / ii n_therapy/whatHow Does Binocular Vision Work? _is_vision_ther apy.htmlhttp://www.vision3d.com/stereo.html 90/97 Position Statement on VT Practice Management AOA, AAO, COVD many others: Position Statement on Myths Optometric Vision Therapy “The American Optometric Association VT i Too Expensive! is T E i ! affirms its long standing position that You Can’t Make Money Doing VT! optometric vision therapy is effective in the treatment of physiological, neuromuscular and perceptual dysfunctions of the vision system……..” Which is it? Can’t have it both ways!
Practice Management Practice Management First All BV Disorders are a Comprehensive Examination Then Th Medical Condition ed ca Co d t o Visual Efficiency CI, CE, DI, DE, Pursuit/Saccade Dysfunction Strab/Amblyopia Follow-up Practice Management Practice Management Accommodative disorders Visual Discomfort te d tend to be refractive e act veAccommodative insufficiency, excess, infacility, is i a medical diagnosis i i i instability, etc 95/97 All Ages Can Benefit…. More Patients Better Patient Care Evidenced Based Do it!
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. S Ave Chicago, Il. 60610 Chicago Il 312-949-7280 voice 312-949-7668 fax Private Practice 773-935-2020 MainosMemos.com firstname.lastname@example.org www.LyonsFamilyEyeCare.com www.ico.edu