To BV or Not to BV:VT in the Primary Care Office

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To BV or Not to BV:VT in the Primary Care Office presents information for the primary care optometrist on how to start diagnosing and treating (or make appropriate referrals) disorders of the binocular vision system.

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To BV or Not to BV:VT in the Primary Care Office

  1. 1. To BV or Not to BV: VT in the Primary Care Office Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor Illinois Eye Institute Illinois College of Optometry Private Practice Harwood Heights, Il.
  2. 2. BV Dx & Tx in the News!!
  3. 3. BV Dx & Tx in the News!!
  4. 4. BV Dx & Tx in the News!!
  5. 5. BV Dx & Tx in the News!!
  6. 6. Non-strabismic BV disorders Prevalence • Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5% • Convergence Excess: ~6% • Accommodative disorders: 3-5%
  7. 7. Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work
  8. 8. Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work
  9. 9. Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work
  10. 10. Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work
  11. 11. Visual Efficiency Examination: Basic Tests • Visual acuity – May find reduced acuity at near or complaints of blur at near (intermittent problems) • Cover test – Distance and near – Repeat during the exam to see if fatigue changes your result • Nearpoint of convergence – Repeat several times
  12. 12. Visual Efficiency Examination: Basic Tests • Visual acuity – May find reduced acuity at – near or complaints of – blur at near • Cover test – Distance and near – Repeat during the exam to see if fatigue changes your result • Nearpoint of convergence – Repeat several times
  13. 13. Visual Efficiency Examination: Basic Tests • Visual acuity – May find reduced acuity at – near or complaints of – blur at near • Cover test – Distance and near – Repeat during the exam to see if – fatigue changes your result • Nearpoint of convergence – Repeat several times
  14. 14. Basic tests • Stereopsis – Look for reduced steropsis • Less than 70 seconds of arc • Accommodative amplitude – Either push-up method or minus lens method – Minimum amplitude = 15 - (0.25) age – So a 20 year old should have at least 10 diopters of accommodation
  15. 15. Basic tests • Stereopsis – Look for reduced steropsis • Less than 70 seconds of arc • Accommodative amplitude – Either push-up method or minus lens method – Minimum amplitude = 15 - (0.25) age – So a 20 year old should have at least 10 diopters of accommodation
  16. 16. Basic tests • Accommodative facility – Perform monocularly and binocularly with suppression control (+/-2.00) • ~10 cycles per minute is diagnostic • Vergences – Use either prism bars or Risley prisms – Sheard’s criteria • Need twice your phoria in reserve • Example: a 10 pd exophore at near needs 20 pd BO reserves
  17. 17. Basic tests • Accommodative facility – Perform monocularly and binocularly – with suppression control (+/-2.00) • ~10 cycles per minute is diagnostic • Vergences – Use either prism bars or Risley prisms – Sheard’s criteria • Need twice your phoria in reserve • Example: a 10 pd exophore at near needs 20 pd BO reserves
  18. 18. Other tests • Phorias – Von Graefe phorias – Maddox Rod techniques • Suppression – Worth 4 Dot
  19. 19. Other tests • Phorias – Von Graefe phorias – Maddox Rod techniques • Suppression – Worth 4 Dot
  20. 20. Other Tests • Dynamic Retinoscopy – Monocular Estimation Method – Expected Values: +0.50 to +0.75 D • Fixation Disparity Testing – Wesson Card – Bernell Fixation Disparity (Associated Phoria) – Disparometer
  21. 21. Other Tests • Fixation Disparity Testing – Wesson Card – Bernell Fixation Disparity (Associated Phoria) – Disparometer
  22. 22. Other Tests • Fixation Disparity Testing – Wesson Card – Bernell Fixation Disparity (Associated Phoria) – Disparometer
  23. 23. Other Tests • Fixation Disparity Testing – Wesson Card – Bernell Fixation Disparity (Associated Phoria) – Disparometer
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. Accommodative Disorders • Symptoms: blur, headache, aesthenopia, fatigue when reading, difficulty changing focus from one distance to another
  30. 30. 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
  31. 31. Other BV Disorders • Divergence Excess – Prevalence of ~0.5 to 4% – Exophoria greater at distance than near – Frequently first discovered in grade school • Divergence Insufficiency – Very rare! – Esophoria greater at distance than near – Be careful to rule out lateral rectus palsy!
  32. 32. Strabismus & Amblyopia 3-5% of the population Tx appropriate at all ages May do out of office VT and achieve success!
  33. 33. Exotropia CI, Intermittent XT @ near DE, Intermittent XT @ distance
  34. 34. Accommodative Esotropia First seen in 2-4 year olds Uncorrected hyperopia High ACA
  35. 35. Diplopia & Head Turns/Tilts Paresis or paralysis? Duane’s Retraction Syndrome
  36. 36. Amblyopia Pathological until proven otherwise Infants/Toddlers Young Children Busy Adults
  37. 37. Amblyopia Pathological until proven otherwise Anisometropia Infants/Toddlers Bilateral Refractive Error Young Children Strabismus (Constant) Busy Adults
  38. 38. 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.
  39. 39. 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.
  40. 40. 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.
  41. 41. 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.
  42. 42. 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.
  43. 43. 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
  44. 44. Treatment for BV Disorders • Treatment modalities – Lenses – Prisms – Vision therapy • Traditional therapy • Computer therapy
  45. 45. Lenses as Treatment Best Rx (clarity, comfort, function) Refractive Error Amblyopia Binocularity Interference Rx if…. Concern Concerns with Learning Myopia >5.00D Under correct Depends >5.00D (any age) eso/Fully on child’s >3.00D @>1yr correct exo age Hyperopia >2.00D Under correct >2.50D >2.00D exo/Fully correct eso Astigmatism >1.25D Depends >1.25D on VA Anisometropia >1.00D Monitor >1.00D >1.00D BV/Stereo
  46. 46. 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
  47. 47. Bifocals for Kids Bifocal Seg Height Infants/Toddlers Pre-schoolers Bi-sect pupil
  48. 48. Bifocals for Kids Bifocal Seg Height 3-5 Years Bottom 1/3 of Pupil
  49. 49. Bifocals for Kids Bifocal Seg Height > 5yrs Bottom of Pupil
  50. 50. 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.
  51. 51. Bifocals for Myopia Progression . PALs were effective in slowing progression in these children, with statistically significant 3-year treatment effects (mean +/- SE) for those with larger lags in combination with near esophoria (PAL - SVL progression = -1.08 D - [-1.72 D] = 0.64 +/- 0.21 D), shorter reading distances (0.44 +/- 0.20 D), or lower baseline myopia (0.48 +/- 0.15 D). The 3-year treatment effect for larger lags in combination with more hours of near work was 0.42 +/- 0.26 D, which did not reach statistical significance. Statistically significant treatment effects were observed in these four groups at 1 year and became larger from 1 to 3 years. CONCLUSIONS: 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.
  52. 52. Polycarbonate Lenses
  53. 53. 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
  54. 54. 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
  55. 55. 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?)
  56. 56. Vision Therapy for Amblyopia • Prescribe Rx • Implement occlusion therapy • Active vision therapy • Monitor • Change Rx/Tx as needed
  57. 57. Period of Sensitivity vs Period of Plasticity
  58. 58. 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.
  59. 59. Atropine OBJECTIVE: To compare daily atropine to weekend atropine as prescribed treatments for moderate amblyopia in children younger than 7 years. PARTICIPANTS: One hundred sixty-eight children younger than 7 years with amblyopia in the range of 20/40 to 20/80 associated with strabismus, anisometropia, or both. INTERVENTION: Randomization either to daily atropine or to weekend atropine for 4 months. Partial responders were continued on the randomized treatment until no further improvement was noted. MAIN OUTCOME MEASURE: Visual acuity (VA) in the amblyopic eye after 4 months. RESULTS: The improvement in VA of the amblyopic eye from baseline to 4 months averaged 2.3 lines in each group. The VA of the amblyopic eye at study completion was either (1) at least 20/25 or (2) better than or equal to that of the sound eye in 39 children (47%) in the daily group and 45 children (53%) in the weekend group. The VA of the sound eye at the end of follow-up was reduced by 2 lines in one patient in each group. Stereoacuity outcomes were similar in the 2 groups. 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.
  60. 60. 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.
  61. 61. Atropine PURPOSE: To assess the course of the response to atropine treatment of moderate amblyopia and to assess factors predictive of the treatment response in children 3 years old to younger than 7 years old. METHODS: A total of 195 children 3 years old to younger than 7 years of age with amblyopia in the range of 20/40 to 20/100 from the atropine treatment arm of this trial were enrolled and included in this analysis. At baseline, daily topical atropine was prescribed for the sound eye. During follow-up, a plano spectacle lens was prescribed for the sound eye for patients whose amblyopia had not been successfully treated with atropine alone. Follow-up examinations were performed at 5 weeks, 16 weeks, and 6 months. The primary outcome measure was visual acuity in the amblyopic eye at 6 months. CONCLUSIONS: 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.
  62. 62. 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
  63. 63. Amblyopia Therapy What do we know about amblyopia? – More than decreased VA – Visual-Spatial affects – Accommodation – Hand-eye – Stereopsis
  64. 64. Active Vision Therapy Hand-eye Oculomotor Accommodation Have child “Do Stuff” Interact with environment
  65. 65. Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 PURPOSE: Anisometropia of more than one dioptre during the sensitive visual period may cause amblyopia. Its management requires refractive correction, and occlusion. Compliance with treatment is critical if visual improvement is to obtained. High anisometropia, poor initial acuity and mixed strabismic/anisometropia amblyopia are predictive factors for a poor outcome. We evaluated contact lens use in the management of high anisometropic amblyopia. METHODS: Retrospective analysis of anisometropic amblyopia managed in a paediatric contact lens clinic after standard amblyopia therapy of spectacles and occlusion therapy had been tried. RESULTS: Seven children (four male, three female) presented at age 3.5-6 years (mean 4.5). Six had myopic anisometropia 6.0-18.4 dioptres (mean 10.4 dioptres) and one 6.75 dioptres hypermetropic anisometropia. The initial corrected acuities of the amblyopic eyes were 6/18 to 1/60. Five patients used contact lenses with a range from 5 months to 4 years. Final acuities were 6/12-1/60. Two myopes with 6 dioptres anisometropia improved three to four Snellen lines, one with 8.8 dioptres improved one line. Three with >10 dioptres anisometropia did not improve. The hypermetropic patient improved part of one Snellen line. CONCLUSIONS: High anisometropic amblyopia is challenging to treat. In our study contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres.
  66. 66. 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!
  67. 67. 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!
  68. 68. 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!
  69. 69. 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!
  70. 70. 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!
  71. 71. Traditional Therapy Procedures • Hand-Eye Procedures – mazes – dot to dot – cutting – coloring – filling in O’s
  72. 72. Traditional Therapy Procedures • Vergence procedures – Brock String – Lifesaver card – Anaglyph Series (BC920, others) • Accommodative Procedures – Minus lens dips – Flippers – Hart Chart
  73. 73. Vergence Procedures Brock String Simple Inexpensive Easy Effective
  74. 74. Vergence Procedures Life Saver Cards BO and BI Good fusion Anti-suppression Inexpensive Effective
  75. 75. Vergence Procedures Fusion Cards Random dot targets BC 920, BC 50 Anaglyph series
  76. 76. Vergence Procedures Aperture Rule “Flying W” Stereoscopes
  77. 77. Accommodative Procedures Rock Card Flippers Anti-suppression
  78. 78. Accommodative Procedures Hart Chart the old standby
  79. 79. 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
  80. 80. Computer Vision Therapy • Computer based vision therapy program • Patient can use at home, work, wherever they have access to computer • Trains eye movements, vergences, accommodation, and perceptual skills
  81. 81. 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
  82. 82. 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
  83. 83. Computer Aided VT Resources Neuroscience Center of Indianapolis http://www.neuroscience.cnter.com/
  84. 84. Computer Aided VT Resources Computer Orthoptics HTS (Home Therapy System) http://www.homevisiontherapy.com/
  85. 85. Computer Aided VT Resources Computerized Aided Vision Therapy Gary Vogel, OD, FAAO Available from Bernell 800-348-2225 http://www.bernell.com/
  86. 86. Computerized Aided Vision Therapy Module 1 Track and Read Visual attention/fixation test Visual reaction time test Short term visual memory test Eye tracking test
  87. 87. Computerized Aided Vision Therapy Module 2: Visual Therapy Visual information processing skills Left-right warm-ups Directional reactions Directional questions Random targets Directional grids Tachistoscopic arrows Satellite commando game
  88. 88. Computerized Aided Vision Therapy Module 2: Visual Therapy Visual Skills Therapy Tic-Tac-Toe rotations Spatial Sequencing Spatial Patters BPDQ Grids Circles, Boxes, Triangles Geo Boards Rotating patterns
  89. 89. Computerized Aided Vision Therapy Module 2: Visual Therapy Therapy Procedures Visual attention/fixation Tracking with Numbers Span of recognition Random eye movements Short term visual memory Large angle eye movements
  90. 90. Computerized Aided Vision Therapy Module 2: Visual Therapy Visual Figure Ground Skills Target counting Character searching Letter locator Dot to dot Shapes Hidden patterns
  91. 91. Computerized Aided Vision Therapy Module 2: Visual Therapy Visual Closure Skills Therapy Circles & boxes Lines & rectangles Closing on center Closing patterns Letters/numbers dot to dot Closing words Tracking with sequences/words Verbal saccades Tracking with stories
  92. 92. Computerized Aided Vision Therapy Module 3: Computer Vergences Jump vergences (single/double targets) Smooth vergences Pursuit vergences Life saver drills Anti-suppression games
  93. 93. Brainware Safari http://www.brainwareforyou.com/
  94. 94. Brainware Safari Helms D, Sawtelle SM. A study of the effectiveness of cognitive therapy delivered in a video game format. Optom Vis Dev 2007;38(1):19-26. Students in the study group showed an average of 4 years and 3 months improvement on tests of cognitive skills, compared to 4 months improvement for the control group and showed an average of 1 year and 11 months improvement on tests of achievement compared to 1 month for the control group. http://www.brainwareforyou.com/
  95. 95. 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
  96. 96. VT Equipment Use the tools discussed You do not need a whole room of VT “stuff”
  97. 97. WWW Sites for BV/VT NVC Adult Amblyopia Treatment http://www.neuro-vision.com/
  98. 98. WWW Sites for BV/VT NVC Adult Amblyopia Treatment What is the treatment like? During the sessions, the patient sits five feet from a specially designed computer screen in a darkened room, wearing special glasses that occlude the strong eye. The patient uses a mouse to respond to treatment tasks and receive audio feedback through speakers or headphones. To begin the treatment process, a doctor performs an eye examination in order to determine the exact type of lazy eye that the patient has and the visual acuity of the patient. The patient will then begin a series of sessions, generally twenty to forty, depending on the initial visual acuity and the patient's progress throughout the treatment.
  99. 99. WWW Sites for BV/VT Gemstonevision. Org
  100. 100. BV Organizations COVD http://www.covd.org/ OEP http://www.oep.org/ 949-250-8070 AAO BV Section http://www.aaopt.org/secti ons/bvppo/aaobvp.html 301-984-1441
  101. 101. BV Organizations PAVE/Parents Active for Vision Education http://www.pave-eye.com/ Neuro-Optometric Rehabilitation Association http://www.noravc.com/
  102. 102. Patient WWW Sites 3 D Pictures http://www.vision3d.com/optical/ index.shtml#stereogram How Does Binocular Vision Work? http://www.vision3d.com/stereo.html
  103. 103. Patient WWW Sites • http://www.chil dren-special- needs.org/visio n_therapy/what _is_vision_ther apy.html
  104. 104. 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……..”
  105. 105. Practice Management Myths VT is Too Expensive! You Can’t Make Money Doing VT! Which is it? Can’t have it both ways!
  106. 106. Practice Management First Comprehensive Examination Then Visual Efficiency Strab/Amblyopia Follow-up
  107. 107. Practice Management All BV Disorders are a Medical Condition CI, CE, DI, DE, Pursuit/Saccade Dysfunction
  108. 108. Practice Management Accommodative disorders tend to be refractive Accommodative insufficiency, excess, infacility, instability, etc
  109. 109. Practice Management Visual Discomfort is a medical diagnosis
  110. 110. Practice Management/Marketing Use the Internet! Private Office Email Mailing Lists Social/Business Connection Sites Blogs
  111. 111. Private Office
  112. 112. Social/ Professional Connections
  113. 113. Social/ Professional Connections
  114. 114. Social/ Professional Connections
  115. 115. Blogs dmPhotoArt.blogspot.com
  116. 116. Email Mailing Lists Optcom BVPE VTOD
  117. 117. WebServant
  118. 118. Questions? Contact: Dominick M. Maino, OD, MEd, FAAO, FCOVD-A Professor, Pediatric/Binocular Vision Service Illinois Eye Institute/Illinois College of Optometry 3241 S. Michigan Ave. Chicago, Il. 60610 312-949-7280 voice 312-949-7668 fax Private Practice 708-867-7838 dmaino@ico.edu MainosMemos.blogspot.com www.nw.optometry.net www.ico.edu

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