diagnosing learning related vision problems

Diagnosing and Treating Learning Related Vision Problems

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

ProfessorIllinois Eye Institute

Illinois College of Optometry

Private PracticeHarwood Heights, Il.

Diagnosing and Treating Learning Related Vision Problems

What do Doctors do (or should do) to diagnose LRVP?

Where’s the research?

What Therapy Procedures Should I Use?

What’s New?

BV Dx & Tx in the News!!

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3 D Movie Stars…Can’t See 3D!

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3-D TV and Movies Look to Attract Viewers But Not Everyone Can 'See' What All the Hype is About

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Healthbeat Report: The 3-D Dilemma

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3 D Classroom!

…Studies have shown that the measurableeducational benefits of presenting teachingmaterials in 3D are significant, generating a threefold improvement in comprehension and

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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 …

AOA/[email protected]

Non-strabismic BV disordersPrevalence

Prevalence of General Dysfunctions in Binocular Vision . Montés-Micó Robert. Annals of Ophthalmology, Volume 33, Number 3, September 2001 , pp. 205-208(4). (Spain)

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…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%). …

BV disorders

Prevalence

Pickwell's Binocular Vision Anomalies By Bruce

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J. W. Evans, David Pickwell

Between 1 in 5 to 1 in 10 individuals have BV problems. 30-60 million people

BV disorders

Prevalence

Prevalence and risk factors for common vision problems in children (in the UK)

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problems in children (in the UK)

…for 7825 seven-year-old children. 2.3% had manifest strabismus, 3.6% had …amblyopia….

Non-strabismic BV disorders

Prevalence

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

W i d 265 t ti ti t 59

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….We examined 265 symptomatic patients …., 59 patients (22.3%) had some form of accommodativeor 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%).

BV disorders

Prevalence: Additional Articles

Prevalence of general binocular dysfunctions in a population of university students

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population of university students.

32.3% of the subjects showed general

binocular dysfunctions

BV disorders


Stereoacuity levels and vision problems

i hild f 7 t 11

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in children from 7 to 11 years

…prevalence of defective stereoscopic vision was

found to be between 2.1 and 3.2 per cent

BV disorders


Prevalence of amblyopia in

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Prevalence of amblyopia in

ametropias in a clinical set-up

…Out of 970 ametropic eye patients a total of 56 (5.97%)

patients have amblyopia….

Non-strabismic BV disorders

Prevalence

• Convergence Insufficiency: 1.3% to 37% of

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the population; most report 3-5%

• Convergence Excess: ~6%

• Accommodative disorders: 3-5%

AOA: Care of the Patient with Accommodative and Vergence Dysfunction

http://www.aoa.org/documents/CPG-18.pdf

What Does the Doctor Do to

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Diagnose Learning Related Vision Problems?

Can We Measure Symptoms

Test-retest reliability of the college of optometrists in vision development quality of life outcomes assessment. MAPLES W. C. , et al.

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,

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


Evaluating Changes in Quality of Life After Vision Therapy Using the COVD Quality of Life Outcomes Assessment Kelly M. Daugherty,

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OD, et. al.

The COVD – QOL Questionnaire in a socially at-risk population of youth Willard B. Bleything, OD, MS, FAAO, FCOVD, Sandra L. Landis, OD, FCOVD


Validity of the convergence insufficiency symptom survey: a confirmatory study.

Rouse M, Borsting E, Mitchell GL, et al.

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, g , ,

…The CISS continues to be a valid instrument for quantifying symptoms in 9 to <18-year-old children…

Subjective Complaints of Patients with BV Disorders

• Blurd h

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• Headache

• Aesthenopia

• Diplopia

• These complaints are usually associated with near work


• Blur

H d h

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• Headache• Aesthenopia• Diplopia



• Blur

H d h

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• Headache

• Aesthenopia

• Diplopia• These complaints are usually

associated with near work


• Blur

H d h

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• Headache

• Aesthenopia

• Diplopia


Examination Sequence

Comprehensive Eye/Vision Examination

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Visual Efficiency Examination

Vision Information Processing Examination


Comprehensive Eye/Vision Examination

History

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Visual Acuity

Oculomotor/Entrance Tests

Refraction

Eye Health


Visual Efficiency EvaluationHX

(Symptoms related to near work, school,

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(Sy pto s e ated to ea wo , sc oo ,sports, BV dysfucntions, etc.)

VAOculomotor System

Sensory Fusion SystemMotor Fusion/Vergence System

Accommodative System

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Visual Efficiency

Examination

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Visual Efficiency

Examination


Vision Information Processing Examination

Laterality/Directionality

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Laterality/DirectionalityVisual Information Processing Non-motor

Visual Information Processing MotorOculomotor

Auditory Information ProcessingMisc.

VIP

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VIP

VIP

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VIP Master

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Problem List

Master

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Problem List

Visual Efficiency Examination: Basic Tests

History

M b d d h hild

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Must be geared towards the child or adult with likely binocular vision dysfunction, learning related vision problems or work/recreational related functional vision anomalies.


• Visual acuity

– May find reduced it t

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acuity at

near or complaints of

blur at near (intermittent

problems)


Refraction

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Control Lens


Oculomotor System

P i S d

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Pursuits, Saccades

Developmental Eye Movement Test DEM

Visagraph/Readalyzer


Developmental Eye Movement Test DEM J . TASSINARI

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Developmental Eye Movement Test: reliability and symptomatology .Journal of the American Optometric Association ,2005;Volume 76 ,Issue 7 , Pages 387 - 399


• Cover test

–Distance and near

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–Repeat during the exam to see if fatigue changes your result


• Nearpoint of convergence– Repeat several times

See what happens with

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– See what happens with fatique

– Red lens sensitive for CI

A prospective study of different test targets forthe near point of convergenceYi Pang, Helen Gabriel, Kelly A. Frantz and Faheemah Saeed


Heterophoria

In Phoropter

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Prism Bar

Risley Prism/Madox Rod

Other tests

2 Degree Fusion

S i

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Suppression– Worth 4 Dot

Basic tests

StereopsisLook for reduced steropsis

L th 70 d f

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Less than 70 seconds of arc

Basic testsAccommodative amplitude

– Either push-up, push away methods or minus lens

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method– Minimum amplitude

= 15 - (0.25) age– So a 20 year old

should have at least 10 diopters of accommodation

The minus lens method exhibited the best repeatability... Repeatability intra-examiner and agreement in amplitude of accommodation measurements

Antona B, Barra F, Barrio A, Gonzalez E, Sanchez I.

Basic tests

• Accommodative facility– Perform monocularly and

binocularly with suppression control (+/-2 00)

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with suppression control (+/ 2.00)• ~10 cycles per minute is diagnostic

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)

Accommodative function in school children with reading difficulties. Palomo-Alvarez C, Puell MC.

Basic tests

NRA

Negative Relative Accommodation

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Accommodation

PRA

Positive Relative Accommodation

Basic tests

• Vergences

– Use either prism bars or Risley prisms

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Risley prisms

– Sheard’s criteria• Need twice your phoria in

reserve

• Example: a 10 pd exophore at near needs 20 pd BO reserves

Other Tests

• Dynamic Retinoscopy

–Monocular

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Estimation Method

–Expected Values:

–+0.50 to +0.75 D

Other Tests

• Fixation Disparity Testing– Wesson Card

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– Wesson Card

– Bernell Fixation Disparity (Associated Phoria)

– Disparometer

Other Tests


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– Wesson Card


– Disparometer

Other Tests


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– Wesson Card


– Disparometer

Other Tests

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Common BV Syndromes

• Convergence Insufficiency

– Most common syndrome

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– Symptoms: aesthenopia, headaches, blur, diplopia, loss of concentration• associated with near work

• often occur near the end of the day

Convergence Insufficiency

• Signs:– An exodeviation at near

• Can even be an intermittent exotropia at near

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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

Convergence Excess

• Symptoms: Diplopia, headaches, aesthenopia– almost always near related

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– 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

Convergence Excess

• Signs

– Dynamic Retinoscopy

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• 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

Binocular Vision Dysfunction

• Symptoms: aesthenopia, headaches, blurred vision (Binocular Vision/Visual Discomfort Dx)

– Associated with reading or near work

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– Associated with reading or near work

• Signs: – Phorias: Normal at distance and near

– Reduced BI and BO vergences at distance and/or near

Accommodative Disorders

• Symptoms: blur, headache, aesthenopia fatigue

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aesthenopia, fatigue when reading, difficulty changing focus from one distance to another

Accommodative Disorders

• Signs– Accommodative Insufficiency:

• Reduced amplitude of accommodation

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Reduced amplitude of accommodation

• Minimum Accommodation: 15 - (0.25) (age)

– Accommodative Infacility• Failure of monocular facility testing

• Expected value: 11 cpm

Other BV Disorders

• Divergence Excess– Prevalence of ~0.5 to 4%

Exophoria greater at distance than near

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– 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!

Strabismus & Amblyopia

3-6% of the population

T i ll

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Tx appropriate at all ages

May do out of office VT

and achieve success!

Exotropia

CI, Intermittent XT @ near

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@

DE, Intermittent XT @ distance

Accommodative Esotropia

First seen in 2-4 year olds

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Uncorrected hyperopia

High ACA

Accommodative Esotropia

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From: http://www.strabismus.org/esotropia_eye_turns_in.html

Diplopia & Head Turns/Tilts

Paresis or paralysis?

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Duane’s Retraction Syndrome

Amblyopia

Pathological until proven otherwise

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Infants/Toddlers

Young Children

Busy Adults

Amblyopia

Pathological until proven otherwise AnisometropiaAnisometropia

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p

Infants/Toddlers

Young Children

Busy Adults

pp

Bilateral Refractive ErrorBilateral Refractive Error

Strabismus (Constant)Strabismus (Constant)

No No disease presentdisease present

Efficacy of Optometric Vision Therapy

Efficacy of vision therapy as assessed by the COVD quality of life checklist. Maples WC, Bither M

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Bither M.

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.


Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in

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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.

i i h / h i h

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…vision therapy/orthoptics was the only treatment that produced clinically significant improvementsin the near point of convergence and positive fusional vergence.


A Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children Mitchell Scheiman, OD, FCOVD, CITT Study Chair

Office Based Vergence/Accommodation Therapy

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Office Based Vergence/Accommodation Therapy was significantly more effective than 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

Treatment for BV Disorders

Evidence Based Medicine

Cotter S et al Treatment of strabismic amblyopia with

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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 …that strabismic amblyopia can improve and even resolve with spectacle correction alone.


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.

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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

Refractive ErrorMyopia: Can Its Progression Be Controlled? Yi Pang, PhD, OD, Dominick M. Maino, OD, MEd, FAAO Guoming Zhang, MD, PhD, Fan Lu, MD, OD

…. …. muscarinic receptor antagonists, including

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usca c ecepto a tago sts, c ud gatropine 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.

Refractive ErrorTwo-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 . Et

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al.al.

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)

New Amblyopia Treatments?

Thompson B, Mansouri B, Koski L, Hess RF. Brain plasticity in the adult: modulation of function in amblyopia with

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modulation of function in amblyopia with rTMS. Curr Biol. 2008 Jul 2;18(14):1067-71.

Watch for studies on “Perceptual Learning”!

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

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…..video-game play may provide important principles for treating amblyopia, and perhaps other cortical dysfunctions.

Learning Related Vision Problems

All vision problems affect learning, usually as a secondary contributing f t

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factor.

New research suggests that the Magnocellular pathway may show a direct vision link.


Repeatability of the VMI Supplemental Developmental Test of Visual Perception Marjean Taylor Kulp, OD, MS, FAAO and Michael J. Earley, OD, PhD, FAAO

Visual perceptual ability has been found to be related

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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.

• It give repeatable results.


Subitizing and Visual Counting in Children with Problems in Acquiring Basic Arithmetic SkillsBurkhart Fischer, Dipl. Phys., Christine Gebhardt, Dipl.

h d l i l h

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Phys., and Klaus Hartnegg, Dipl. Phys.

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.

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.


Effects of Daily Practice on Subitizing, Visual Counting, and Basic Arithmetic Skills Burkhart Fischer, Dipl. Phys., Christine Gebhardt, Dipl. Phys., and Klaus Hartnegg, Dipl. Phys.

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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.

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.


Solan H et al. M-cell deficit and reading disability: a preliminary study of the effects of temporal vision-processing therapy.

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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.


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.

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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.


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.

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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.

Optom Vis Dev. 2007;38(1)


Vision, Visual-Information Processing, and Academic Performance Among Seventh-Grade Schoolchildren: A More Significant Relationship Than We Thought? Sarina

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Goldstand, Kenneth C. Koslowe and Shula Parush American Journal of Occupational Therapy July/August 2005 vol. 59 no. 4 377-389

Effect of attention therapy on reading comprehension.Solan HA, Shelley-Tremblay J, Ficarra A, Silverman M, Larson S. J Learn Disabil. 2003 Nov-Dec;36(6):556-63.


A randomized prospective masked and matched comparative study of orthoptic treatment versus conventional reading tutoring treatment for reading

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disabilities in 62 children.

Atzmon D, Nemet P, et al.Binocular Vision & Eye Muscle Surgery Quarterly, 8(2):p. 91-106, 1993.

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

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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.

Optometric Vision Therapy are NOT!

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Eye Exercisers!

Vision Therapy is…..!

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Brain TherapyNeuro-therapyNeuro-plasticity Therapy


• Treatment modalities– Lenses

Prisms

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– Prisms

– Vision therapy• Traditional therapy

• Computer therapy

Lenses as TreatmentBest Rx (clarity, comfort, function)

Refractive Error Amblyopia Concern

Binocularity Concerns

Interference with Learning

Rx if….

Myopia >5.00D Under correct eso/Fully

Depends on child’s

>5.00D (any age)

>3.00D @>1yr

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correct exoo c d sage

Hyperopia >2.00D Under correct

exo/Fully correct eso

>2.50D >2.00D

Astigmatism >1.25D Depends on VA

>1.25D

Anisometropia >1.00D Monitor BV/Stereo

>1.00D >1.00D

Lenses as Treatment

• Best Rx (clarity, comfort, function)

• Accommodative disorders

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– Can prescribe reading only Rx or an add

• Exodeviations – Overminusing (DE)

– Not usually a first choice! Give add

Bifocals for Kids

Bifocal Seg Height

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Infants/Toddlers

Pre-schoolers

Bi-sect pupil

Bifocals for Kids

Bifocal Seg Height

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3-5 Years

Bottom 1/3 of Pupil

Bifocals for Kids

Bifocal Seg Height

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> 5yrs

Bottom of Pupil

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

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Invest Ophthalmol Vis Sci. 2004 Jul;45(7):2143-51.

….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…..

Polycarbonate Lenses

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Prism as Treatment

• Can be used with CI, CE, DI, DE, Vertical Deviations

• Prescribe the least amount of prism needed

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• Prescribe the least amount of prism needed– Determine the associated phoria with a Wesson

Card or Bernell Box

• Fresnel Prism trial, then Rx

Optometric Vision Therapy as Treatment

• The approach of choice for CI, Fusional Vergence Dysfunctions, accommodative disorders and Amblyopia

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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

Vision Therapy as Treatment

• Traditional therapy– Hand-eye, Vergence and Accommodative

procedures

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procedures

• Computer Therapy– Can attack hand-eye, vergence, accommodative

and oculomotor problems (Vision information processing anomalies?)

Vision Therapy for Amblyopia

• Prescribe Rx

• Implement occlusion

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therapy

• Active vision therapy

• Monitor

• Change Rx/Tx as needed

Period of Sensitivityvs

Period of Plasticity

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Period of Plasticity

Atropine

Pediatric Eye Disease Investigator Group.The course of moderate amblyopia (20/100) treated with atropine in children:

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treated with atropine in children: experience of the amblyopia treatment study.Am J Ophthalmol. 2003 Oct;136(4):630-9.

Atropine

Repka MX, Cotter SA, Beck RW, Kraker RT, Birch EE, Everett DF, Hertle RW, Holmes JM, Quinn GE, Sala NA, Scheiman MM,

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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

Weekend atropine provides an

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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.

Occlusion TherapyAge (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

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Amblyopia Therapy

What do we know about amblyopia?

M h d d VA

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– More than decreased VA

– Visual-Spatial affects

– Accommodation

– Hand-eye

– Stereopsis

Active Vision Therapy

Hand-eye

Oculomotor

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Accommodation

Have child “Do Stuff”

Interact with environment

Roberts CJ, Adams GG.Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10

High anisometropic amblyopia is

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g p y pchallenging to treat. …contact lenses improved visual acuity in myopic anisometropia of up to 9 diopters.


Phases of Therapy• Monocular (HE, OM, ACC)

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• Biocular (HE, OM, ACC, Anti-suppression)

• Binocular (Vergence, Acc)

• Integration/Stabilization

Do it all at the same time!



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Traditional Therapy Procedures

• Hand-Eye Procedures– mazes

dot to dot

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– dot to dot

– cutting

– coloring

– filling in O’s

– Bunt Ball

Traditional Therapy Procedures

• Vergence procedures– Brock String

Lifesaver card BI and BO

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– Lifesaver card BI and BO

– Anaglyph Series (BC920, others)

• Accommodative Procedures– Minus lens dips

– Flippers

– Hart Chart

Vergence Procedures

Brock String Simple

Inexpensive

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InexpensiveEasy

Effective

Brock String

Vergence Procedures

Life Saver Cards

BO d BI

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BO and BI

Good fusion

Anti-suppression

Inexpensive

Effective

Vergence Procedures

Fusion Cards

Random dot

123

targets

BC 920, BC 50

Anaglyph series

Aperture Rule Aperture Rule

Eccentric Circles

Vergence Procedures

Aperture Rule

“Flying W”

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StereoscopesVectograms

Vectograms

Accommodative Procedures

Rock Card

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Flippers

Anti-suppression

Accommodative Procedures

Hart Chart

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the old standby

Vision Therapy Videos

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http://www.youtube.com/watch?v=HtzEHSie-90


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http://www.youtube.com/watch?v=fX8mqtgdzgs


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http://www.youtube.com/watch?v=RTy3o8DwON8


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http://www.youtube.com/watch?v=Ui3KTZOdzbohttp://www.youtube.com/watch?v=wcVX684r3xQ

Computer Vision Therapy

• Can attack vergence, accommodative, and oculomotor problems

• Most programs are set up to record patient’s performance each session

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– Removes the problem of compliance!

• Different products on the market– Home Therapy System

– Computer Aided Vision Therapy

Computer Vision Therapy

• Computer based vision therapy program

• Patient can use at home, work, wherever they have access to computer

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they have access to computer

• Trains eye movements, vergences, accommodation, and perceptual skills

Why use Computer Aided VT?

• “Patients who cannot make a time commitment

• Patient compliance problems

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• Patient compliance problems

• Insurance or Third Party Problems

• It’s Fun!

How do you incorporate Computer Aided Vision

Therapy in your program?

• Diagnose the patient!!!

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Diagnose the patient!!!

• Assign a therapy protocol

• Computer aided VT in the office

• Schedule follow-up appointments

• Evaluate the patient’s progress/Follow-up

Computer Aided VT Resources

Computer Orthoptics HTS (Home Therapy System)

http://www.homevisiontherapy.com/

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136


137


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Computerized Aided Vision TherapyGary Vogel, OD, FAAO

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http://www.cavt.net/software.html

Available from Bernell 800-348-2225 http://www.bernell.com/

Computerized Aided Vision Therapy

Module 1 Track and Read

Visual attention/fixation test

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Visual attention/fixation test

Visual reaction time test

Short term visual memory test

Eye tracking test


Module 2: Visual TherapyVisual information processing skills

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Left-right warm-ups Directional reactions

Directional questions Random targets

Directional grids Tachistoscopic arrows

Satellite commando game


Module 2: Visual Therapy

Visual Skills Therapy

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py

Tic-Tac-Toe rotations Spatial Sequencing

Spatial Patters BPDQ Grids

Circles, Boxes, Triangles Geo Boards

Rotating patterns


Module 2: Visual TherapyTherapy Procedures

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pyVisual attention/fixation Tracking with Numbers

Span of recognition Random eye movements

Short term visual memory

Large angle eye movements


Module 2: Visual TherapyVisual Figure Ground Skills

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Visual Figure Ground Skills

Target counting Character searching

Letter locator Dot to dot

Shapes Hidden patterns


Module 2: Visual TherapyVisual Closure Skills Therapy

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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


Module 3: Computer Vergences

Jump vergences (single/double targets)

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Ju p ve ge ces (s g e/doub e ta gets)

Smooth vergences Pursuit vergences

Life saver drills

Anti-suppression games

Vision Builder

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Brainware Safari

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http://www.brainwareforyou.com/

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.

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; ( )

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/

Conclusions

• Easy to incorporate VT for BV disorders into your activities

• Monitor the output to check for compliance

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• Monitor the output to check for compliance and tricks!

• Remember that the key is in diagnosing patients and follow-up

VT Equipment

Use the tools discussed

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You do not need a whole room of

VT “stuff”

WWW Sites for BV/VT

Gemstonevision.Org

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BV Organizations

COVD http://www.covd.org/

OEP http://www.oepf.org//

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949-250-8070

AAO BV Sectionhttp://www.aaopt.org/section/bv/index.asp

301-984-1441

BV Organizations

PAVE/Parents Active

for Vision Education

htt // i i /

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http://www.pavevision.org/

Neuro-Optometric

Rehabilitation Association

http://www.nora.cc/

Patient WWW Sites

3 D Pictures

http://www.vision3d.com/optical/

i d ht l# t

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index.shtml#stereogram

How Does Binocular Vision Work?

http://www.vision3d.com/stereo.html

Patient WWW Sites

• http://www.children-special-

d / i i

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needs.org/vision_therapy/what_is_vision_therapy.html

Position Statement on VTAOA, AAO, COVD many others:

Position Statement on

Optometric Vision Therapy

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“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……..”

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My Private Office

MainosMemos, Facebook, LinkedIn, ICO

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161

Social/ProfessionalConnections

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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

[email protected] MainosMemos.blogspot.com

www.nw.optometry.net www.ico.edu

diagnosing learning related vision problems

Health & Medicine