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

1. Diagnosing and Treating
Diagnosing and Treating Learning Related Vision Problems
Learning Related Vision Problems
What do Doctors do (or should do) to
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
diagnose LRVP?
Professor Where’s the research?
Illinois Eye Institute
Illinois College of Optometry What Therapy Procedures Should I
Private Practice Use?
Harwood Heights, Il.
What’s New?
BV Dx & Tx in the News!!
3 4
3 D Movie Stars…Can’t See 3D!
5 6

2. 3-D TV and Movies Look to Attract Viewers But Not Healthbeat Report: The 3-D Dilemma
Everyone Can 'See' What All the Hype is About
7 8
3 D Classroom!
Non-strabismic BV disorders
…Studies have shown that the measurable Prevalence
educational benefits of presenting teaching Prevalence of General Dysfunctions in Binocular Vision . Montés-
Micó Robert. Annals of Ophthalmology, Volume 33, Number 3,
materials in 3D are significant, generating a September 2001 , pp. 205-208(4). (Spain)
threefold improvement in comprehension and
retention over the more traditional non - 3D …in 1679 subjects aged 18 to 38 years. …. A high
prevalence of binocular vision dysfunctions was
style of presentation. And students respond found. … 56.2% presented symptoms of binocular
well to the immersive and engaging qualities of dysfunctions, 61.4% with accommodation
the 3D effect … disorders and 38.6% vergence disorders.
Accommodation insufficiency was most prevalent
AOA/3D@Home among those with symptoms (11.4%). …
www.3Dhealth.org 9 10
BV disorders BV disorders
Prevalence Prevalence
Prevalence and risk factors for common vision
Pickwell's Binocular Vision Anomalies By Bruce
problems in children (in the UK)
J. W. Evans, David Pickwell
Between 1 in 5 to 1 in 10 individuals have …for 7825 seven-year-old children.
BV problems. 30-60 million people 2.3% had manifest strabismus,
3.6% had …amblyopia….
11 12

3. Non-strabismic BV disorders BV disorders
Prevalence
General binocular disorders: prevalence in a clinic population. Ophthalmic & Prevalence: Additional Articles
Physiological Optics. 21(1):70-74, January 2001.Lara, Francisco 2; Cacho, Pilar 1; Garcia,
Angel 1; Megias, Ramon 2 Prevalence of general binocular dysfunctions in a
….W
We examined 265 symptomatic patients …., 59
i d t ti ti t population of university students.
students
patients (22.3%) had some form of accommodative
or binocular dysfunction …. The frequency of
binocular dysfunctions was 12.9%, and 9.4% for 32.3% of the subjects showed general
accommodative anomalies. Convergence excess
(4.5%) was more prevalent than convergence binocular dysfunctions
insufficiency (0.8%) and accommodative excess
(6.4%) more prevalent than accommodative
13 14
insufficiency (3%).
BV disorders BV disorders
Prevalence: Additional Articles Prevalence: Additional Articles
Stereoacuity levels and vision problems
in hild
i children from 7 to 11 years
f t Prevalence of amblyopia in
ametropias in a clinical set-up
…prevalence of defective stereoscopic vision was
found to be between 2.1 and 3.2 per cent (5.97%)
…Out of 970 ametropic eye patients a total of 56
patients have amblyopia….
15 16
Non-strabismic BV disorders
What Does the
Prevalence
• Convergence Insufficiency: 1.3% to 37% of
Doctor Do to
the population; most report 3-5%
• Convergence Excess: ~6% Diagnose Learning
• Accommodative disorders: 3-5%
AOA: Care of the Patient with Accommodative and Vergence Dysfunction
Related Vision
http://www.aoa.org/documents/CPG-18.pdf
17
Problems? 18

4. Can We Measure Symptoms Can We Measure Symptoms
Test-retest reliability of the college of optometrists in Evaluating Changes in Quality of Life After
vision development quality of life outcomes Vision Therapy Using the COVD Quality of
assessment. MAPLES W. C. , et al. Life Outcomes Assessment Kelly M. Daugherty,
OD, et. al.
The COVD Quality of Life Outcomes Assessment is
a reliable tool to measure changes in symptoms on The COVD – QOL Questionnaire in a socially at-
the basis of optometric intervention-specifically, risk population of youth Willard B. Bleything,
vision therapy OD, MS, FAAO, FCOVD, Sandra L. Landis, OD,
FCOVD
19 20
Subjective Complaints of
Can We Measure Symptoms
Patients with BV Disorders
Validity of the convergence insufficiency
symptom survey: a confirmatory study.
• Blur
Rouse M, Borsting E, Mitchell GL, et al.
, g , ,
• Headache
d h
• Aesthenopia
…The CISS continues to be a valid
• Diplopia
instrument for quantifying
• These complaints are usually
symptoms in 9 to <18-year-old associated with near work
children… 21 22
Subjective Complaints of Subjective Complaints of
Patients with BV Disorders Patients with BV Disorders
• Blur
• Blur
•H d h
Headache • H d h
Headache
• Aesthenopia • Aesthenopia
• Diplopia • Diplopia
• These complaints are usually associated • These complaints are usually
with near work associated with near work
23 24

5. Subjective Complaints of
Examination Sequence
Patients with BV Disorders
Comprehensive Eye/Vision Examination
• Blur
• Headache
H d h
Visual Efficiency Examination
• Aesthenopia
• Diplopia
• These complaints are usually Vision Information Processing Examination
associated with near work
25 26
Examination Sequence Examination Sequence
Comprehensive Eye/Vision Examination Visual Efficiency Evaluation
HX
History (Sy pto s e ated
(Symptoms related to near wo , school,
ea work, sc oo ,
sports, BV dysfucntions, etc.)
Visual Acuity VA
Oculomotor/Entrance Tests Oculomotor System
Sensory Fusion System
Refraction Motor Fusion/Vergence System
Accommodative System
Eye Health 27 28
Visual Visual
Efficiency Efficiency
Examination Examination
29 30

6. Examination Sequence
Vision Information Processing Examination
Laterality/Directionality
Visual Information Processing Non-motor
VIP
Visual Information Processing Motor
Oculomotor
Auditory Information Processing
Misc.
31 32
Master
VIP Problem List
33 34
Visual Efficiency Examination:
Basic Tests
History
Master
Problem List Must be
M b geared towards the child or
d d h hild
adult with likely binocular vision
dysfunction, learning related vision
problems or work/recreational
related functional vision anomalies.
35 36

7. Visual Efficiency Examination: Visual Efficiency Examination:
Basic Tests Basic Tests
• Visual acuity
– May find reduced Refraction
acuity at
it t
near or complaints of
Control Lens
blur at near
(intermittent
problems)
37 38
Visual Efficiency Examination: Visual Efficiency Examination:
Basic Tests Basic Tests
Oculomotor System Developmental Eye Movement Test
DEM J . TASSINARI
Pursuits, S
P i Saccades
d Developmental Eye Movement
Test: reliability and
symptomatology .
Developmental Eye Movement Test Journal of the American
Optometric Association ,2005;
DEM Volume 76 ,
Issue 7 , Pages 387 - 399
Visagraph/Readalyzer
39 40
Visual Efficiency Examination: Visual Efficiency Examination:
Basic Tests Basic Tests
• Cover test • Nearpoint of convergence
– Repeat several times
–Distance and near
– See what happens with
–Repeat during the fatique
exam to see if – Red lens sensitive for CI
fatigue changes
A prospective study of different test targets for
your result the near point of convergence
Yi Pang, Helen Gabriel, Kelly A. Frantz and Faheemah Saeed
41 42

8. Visual Efficiency Examination:
Basic Tests Other tests
Heterophoria 2 Degree Fusion
In Phoropter
Prism Bar Suppression
S i
– Worth 4 Dot
Risley Prism/Madox Rod
43 44
Accommodative
Basic tests amplitude Basic tests
Stereopsis – Either push-up, push
away methods or
Look for reduced steropsis
minus lens
Less th
L than 70 seconds of arc
d f
method
– Minimum amplitude
= 15 - (0.25) age The minus lens method
– So a 20 year old exhibited the best
repeatability...
should have at least
Repeatability intra-examiner and agreement in
10 diopters of amplitude of accommodation measurements
accommodation Antona B, Barra F, Barrio A, Gonzalez E, Sanchez I.
45 43
Basic tests Basic tests
• Accommodative facility NRA
– Perform monocularly and
binocularly Negative Relative
with suppression control (+/-2 00)
(+/ 2.00) Accommodation
• ~10 cycles per minute is diagnostic
PRA
For children with reading problems: Positive Relative
Binocular accommodative facility
values were significantly lower (p <
Accommodative function in
school children with reading
Accommodation
difficulties. Palomo-Alvarez C,
0.05) in the poor readers (4.9 cpm +/- Puell MC.
3.1) than controls (6.3 cpm +/- 2.9)
47 48

9. Basic tests
Other Tests
• Vergences • Dynamic Retinoscopy
– Use either prism bars or –Monocular
Risley prisms Estimation Method
– Sheard’s criteria
–Expected Values:
• Need twice your phoria in
reserve –+0.50 to +0.75 D
• Example: a 10 pd exophore
at near needs 20 pd BO
49 50
reserves
Other Tests Other Tests
• Fixation Disparity • Fixation Disparity
Testing Testing
– Wesson Card – Wesson Card
– Bernell Fixation – Bernell Fixation
Disparity (Associated Disparity (Associated
Phoria) Phoria)
– Disparometer – Disparometer
51 52
Other Tests Other Tests
• Fixation Disparity
Testing
– Wesson Card
– Bernell Fixation
Disparity (Associated
Phoria)
– Disparometer
53 54

10. 55 56
Common BV Syndromes Convergence Insufficiency
• Convergence Insufficiency • Signs:
– Most common syndrome – An exodeviation at near
• Can even be an intermittent exotropia at near
– Symptoms: aesthenopia, – Receded NPC value
headaches, blur, diplopia, loss • NPC larger than 10 cm
of concentration – Reduced BO vergences at near
• associated with near work • Often fail to meet Sheard’s criterion
• often occur near the end of the
day 57 58
Convergence Excess Convergence Excess
• Symptoms: Diplopia, headaches, • Signs
aesthenopia – Dynamic Retinoscopy
– almost always near related
• May be the most significant test
• Signs:
• Typically a high lag of accommodation
– Esophoria at near
• Use detailed accommodative target or you may miss • Lag may be +1.00 to +2.00 DS at 40
the esophoria cm
– Vergences • Lags greater than +2.50 D at 40 cm
• BI vergences at near may not compensate should suggest uncorrected hyperopia 60
59

11. Binocular Vision Dysfunction Accommodative Disorders
• Symptoms: aesthenopia, headaches, blurred • Symptoms: blur,
vision (Binocular Vision/Visual Discomfort Dx) headache,
– Associated with reading or near work aesthenopia,
aesthenopia fatigue
• Signs: when reading,
– Phorias: Normal at distance and near difficulty changing
– Reduced BI and BO vergences at distance
focus from one
and/or near distance to another
61 62
Accommodative Disorders Other BV Disorders
• Signs • Divergence Excess
– Accommodative Insufficiency: – Prevalence of ~0.5 to 4%
• Reduced amplitude of accommodation – Exophoria greater at distance than near
• Minimum Accommodation: 15 - (0.25) (age) – Frequently first discovered in grade school
– Accommodative Infacility
• Divergence Insufficiency
• Failure of monocular facility testing
• Expected value: 11 cpm
– Very rare!
– Esophoria greater at distance than near
– Be careful to rule out lateral rectus palsy!
63 64
Strabismus & Amblyopia Exotropia
3-6% of the population
CI, Intermittent XT @ near
Tx
T appropriate at all ages
i ll
May do out of office VT DE, Intermittent XT @ distance
and achieve success!
65 66

12. Accommodative Esotropia Accommodative Esotropia
First seen in 2-4 year
olds
Uncorrected hyperopia
From:
http://www.strabismus.org/
esotropia_eye_turns_in.ht
High ACA ml
67 68
Diplopia & Head Turns/Tilts Amblyopia
Paresis or paralysis? Pathological until proven otherwise
Infants/Toddlers
Duane’s Retraction
Syndrome Young Children
Busy Adults
69 70
Efficacy of Optometric
Amblyopia
Vision Therapy
Pathological until Efficacy of vision therapy as assessed by the
Anisometropia
p COVD quality of life checklist. Maples WC,
p
proven otherwise Bither MM.
Infants/Toddlers Bilateral Refractive Error
The COVD-QOL can be used to measure
Young Children changes in symptoms, and to objectively
Strabismus (Constant) demonstrate quality of life changes that are
No disease present achieved through optometric vision therapy.
Busy Adults
71 72

13. Efficacy of Optometric Efficacy of Optometric
Vision Therapy Vision Therapy
Ciuffreda KJ. The scientific basis for and Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus
pencil pushups for the treatment of convergence insufficiency in young adults.
efficacy of optometric vision therapy in Optom Vis Sci. 2005 Jul;82(7):583-95.
non-strabismic accommodative and …vision therapy/orthoptics was the
ii h / h i h
vergence disorders. Optometry. only treatment that produced
2002;73(12):735-62 clinically significant improvements
in the near point of convergence
and positive fusional vergence.
73 74
Efficacy of Optometric
Vision Therapy Treatment for BV Disorders
A Randomized Clinical Trial of Treatments for Symptomatic Convergence Evidence Based Medicine
Insufficiency in Children Mitchell Scheiman, OD, FCOVD, CITT Study Chair
Office Based Vergence/Accommodation Therapy Cotter S et al Treatment of strabismic amblyopia with
al.
was significantly more effective than Home Based refractive correction. Am J Ophthalmol. 2007
Jun;143(6):1060-3.
Pencil Pushups, Home Based Computer Vergence/
Accommodation Therapy with PP+, and Office These results support the suggestion …that strabismic
Based Placebo Therapy in improving both the amblyopia can improve and even resolve with spectacle
symptoms and clinical signs associated with correction alone.
symptomatic CI in children
75 76
Treatment for BV Disorders Refractive Error
Myopia: Can Its Progression Be Controlled? Yi Pang, PhD, OD, Dominick M. Maino,
Scheimann M et al. Randomized trial of treatment of amblyopia in OD, MEd, FAAO Guoming Zhang, MD, PhD, Fan Lu, MD, OD
children aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-
47.
…. muscarinic receptor antagonists, including
usca c ecepto a tago sts, c ud g
Amblyopia improves with optical correction alone in about one
fourth of patients aged 7 to 17 years, although most patients who atropine and pirenzepine. Bifocal and
are initially treated with optical correction alone will require progressive lenses can be effective in the
additional treatment for amblyopia. For patients aged 7 to 12 years,
prescribing 2 to 6 hours per day of patching with near visual control of myopia and have greater
activities and atropine can improve visual acuity even if the
amblyopia has been previously treated. For patients 13 to 17 years,
effectiveness for subjects with nearpoint
prescribing patching 2 to 6 hours per day with near visual activities esophoria and a high lag of accommodation.
may improve visual acuity when amblyopia has not been previously
treated 77 78

14. New Amblyopia Treatments?
Refractive Error
Two-year multicenter, randomized, double-masked,
placebo-controlled, parallel safety and efficacy study of Thompson B, Mansouri B, Koski L, Hess
2% pirenzepine ophthalmic gel in children with myopia. RF. Brain plasticity in the adult:
R. Michael Siatkowski MD, Susan A. Cotter OD, MS . Et
modulation of function in amblyopia with
al.
rTMS. Curr Biol. 2008 Jul 2;18(14):1067-
Pirenzepine ophthalmic gel 2% was effective compared with 71.
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) Watch for studies on “Perceptual Learning”!
79 80
Video-Game
Li RW, Ngo C, Nguyen J, Levi DM (2011)
Play Induces Plasticity in the Visual Learning Related Vision Problems
System of Adults with Amblyopia. PLoS Biol
9(8): e1001135. doi:10.1371/journal.pbio.1001135 All vision problems affect learning,
usually as a secondary contributing
…..video-game play may provide factor.
f t
important principles for treating
New research suggests that the
amblyopia, and perhaps other cortical
Magnocellular pathway may show a
dysfunctions. direct vision link.
81 82
Learning Related Vision Problems Learning Related Vision Problems
Repeatability of the VMI Supplemental Developmental Test of Visual
Perception Marjean Taylor Kulp, OD, MS, FAAO and Michael J. Subitizing and Visual Counting in Children with
Earley, OD, PhD, FAAO Problems in Acquiring Basic Arithmetic Skills
Burkhart Fischer, Dipl. Phys., Christine Gebhardt, Dipl.
Visual perceptual ability has been found to be related
to academic achievement. Therefore, the screening of Phys., and Klaus Hartnegg, Dipl. Phys.
h d l i l h
perceptual skills in children should provide valuable information. …
The VMI Supplemental Developmental Test of Visual Perception We concluded that the deficit in a basic visual capacity
(VP) test 1) has been shown to be related to academic performance, 2) may contribute to the problems encountered by children
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 with anomalies in acquiring basic arithmetic skills.
used as a stand-alone screening test of motor-reduced visual
perception. However, its repeatability as a stand-alone screening test Fischer B, Gebhardt C, Hartnegg K. Subitizing and Visual Counting in Children
has not been evaluated. No consistent learning effect appeared to be with Problems in Acquiring Basic Arithmetic Skills. Optom Vis Dev
present upon retest. 2008:39(1):24-29.
• It give repeatable results.
83 84

15. Learning Related
Learning Related Vision Problems
Vision Problems
Effects of Daily Practice on Subitizing, Visual Solan H et al. M-cell deficit and reading
Counting, and Basic Arithmetic Skills Burkhart disability: a preliminary study of the effects of
Fischer, Dipl. Phys., Christine Gebhardt, Dipl. Phys.,
and Klaus Hartnegg, Dipl. Phys. temporal vision-processing therapy.
Since the result of the second study of this paper shows a Optometry. 2004 Oct;75(10):640-50.
transfer from improvements in subitizing to
improvements of basic arithmetic skills one may This research supports the value of rendering temporal vision therapy to children
conclude that the basic visual capacity of subitizing and identified as moderately reading disabled (RD). The diagnostic procedures and
visual number counting contributes to the problem the dynamic therapeutic techniques discussed in this article have not been
encountered by children with dyscalculia. previously used for the specific purpose of ameliorating an M-cell deficit.
Improved temporal visual-processing skills and enhanced visual motion
Fischer B, Gebhardt C, Hartnegg K. Subitizing and Visual Counting in Children discrimination appear to have a salutary effect on magnocellular processing and
with Problems in Acquiring Basic Arithmetic Skills. Optom Vis Dev reading comprehension in RD children with M-cell deficits.
2008:39(1):24-29.
85 86
Learning Related Learning Related
Vision Problems Vision Problems
Solan H et al. Is there a common linkage among reading
The Effects of HTS Vision Therapy Conducted in a School Setting
comprehension, visual attention, and magnocellular on Reading Skills in Third and Fourth Grade Students David Goss,
processing? J Learn Disabil. 2007 May-Jun;40(3):270-8. O.D., Ph.D., FAAO, FCOVD-A, et. al.
Solan H et al. Role of visual attention in cognitive control of oculomotor A Study of the Effectiveness of Cognitive Skill Therapy Delivered in
readiness in students with reading disabilities. Learn Disabil. 2001 Mar- a Video Game Format Don Helms, O.D., and Sara M. Sawtelle, Ph.D.
Apr;34(2):107-18.
Training Direction-Discrimination Sensitivity Remediates a Wide
Eye movement therapy improved eye movements Spectrum of Reading Skills Teri Lawton, Ph.D.
and also resulted in significant gains in reading
comprehension. Optom Vis Dev. 2007;38(1)
87 88
Learning Related Learning Related
Vision Problems Vision Problems
Vision, Visual-Information Processing, and Academic A randomized prospective masked and matched
Performance Among Seventh-Grade Schoolchildren: A comparative study of orthoptic treatment versus
More Significant Relationship Than We Thought? Sarina conventional reading tutoring treatment for reading
Goldstand, Kenneth C. Koslowe and Shula Parush American Journal of Occupational disabilities in 62 children.
Therapy July/August 2005 vol. 59 no. 4 377-389
Atzmon D, Nemet P, et al.
Effect of attention therapy on reading comprehension.
Binocular Vision & Eye Muscle Surgery Quarterly, 8(2):p.
Solan HA, Shelley-Tremblay J, Ficarra A, Silverman M,
91-106, 1993.
Larson S. J Learn Disabil. 2003 Nov-Dec;36(6):556-63.
89 90

16. Orthoptic treatment, to increase convergence Optometric Vision Therapy are
amplitudes to 60 D, is as effective as NOT!
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.
Eye Exercisers!
91 92
Vision Therapy is…..! Treatment for BV Disorders
• Treatment modalities
– Lenses
– Prisms
– Vision therapy
• Traditional therapy
Brain Therapy • Computer therapy
Neuro-therapy
Neuro-plasticity Therapy
93 94
Lenses as Treatment
Best Rx (clarity, comfort, function)
Lenses as Treatment
Refractive Error Amblyopia Binocularity Interference Rx if….
Concern Concerns with
Learning
• Best Rx (clarity, comfort, function)
Myopia >5.00D Under correct Depends >5.00D (any age)
eso/Fully o child’s
on c d s >3.00D @>1yr
• Accommodative disorders
correct exo
age – Can prescribe reading only Rx or an add
Hyperopia >2.00D Under correct >2.50D >2.00D • Exodeviations
exo/Fully
correct eso – Overminusing (DE)
Astigmatism >1.25D Depends >1.25D – Not usually a first choice! Give add
on VA
Anisometropia >1.00D Monitor >1.00D >1.00D
95 96
BV/Stereo

17. 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
97 98
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.
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.
Sci. Jul;45(7):2143-51
> 5yrs ….Children with large lags of accommodation and
Bottom of Pupil 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…..
99 100
Polycarbonate Lenses
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
101 102

18. Optometric Vision Therapy as Treatment Vision Therapy as Treatment
• The approach of choice for CI, Fusional • Traditional therapy
Vergence Dysfunctions, accommodative – Hand-eye, Vergence and Accommodative
disorders,
disorders and Amblyopia procedures
– High chance of success with these disorders • Computer Therapy
– Results are typically long lasting – Can attack hand-eye, vergence, accommodative
– Often can treat these disorders using primarily and oculomotor problems (Vision information
home VT with in-office check-ups processing anomalies?)
103 104
Vision Therapy for Amblyopia
Period of Sensitivity
• Prescribe Rx vs
• Implement occlusion
therapy
Period of Plasticity
• Active vision therapy
• Monitor
• Change Rx/Tx as needed
105 106
Atropine
Atropine
Pediatric Eye Disease Investigator Group. Repka MX, Cotter SA, Beck RW, Kraker RT,
The course of moderate amblyopia (20/100) Birch EE, Everett DF, Hertle RW, Holmes
treated with atropine in children: JM, Quinn GE, Sala NA, Scheiman MM,
experience of the amblyopia treatment Stager DR Sr, Wallace DK; A randomized
trial of atropine regimens for treatment of
study. moderate amblyopia in children.
Am J Ophthalmol. 2003 Oct;136(4):630-9. Ophthalmology. 2004 Nov;111(11):2076-
85.
107 108

19. Atropine
Occlusion Therapy
Age (yrs) Per Day Schedule Minimum Exam
Frequency
1 4 60min periods 1 day on/1 day off Weekly
Weekend atropine provides an 2 3 30min periods 2 day on/1 day off Every 2 wks
improvement in VA of a magnitude 3 3 30min periods 3 day on/1 day off Every 3 wks
similar to that of the improvement
4 2 60min periods 4 day on/1 day off Every 4 wks
provided by daily atropine in treating
moderate amblyopia in children 3 to 7 5 2 60min periods 5 day on/1 day off Every 5 wks
years old. 6 2 60min periods 6 day on/1 day off Every 6 wks
109 110
Amblyopia Therapy Active Vision Therapy
What do we know about Hand-eye
amblyopia?
Oculomotor
–MMore than d
h decreased VAd
– Visual-Spatial affects
Accommodation
– Accommodation
– Hand-eye Have child “Do Stuff”
– Stereopsis Interact with environment
111 112
Vision Therapy as Treatment
Roberts CJ, Adams GG.Contact lenses in the management of
high anisometropic amblyopia. EYE. 2004;18(1):109-10 Phases of Therapy
High anisometropic amblyopia is
g p y p • Monocular (HE, OM, ACC)
challenging to treat. …contact • Biocular (HE, OM, ACC, Anti-suppression)
lenses improved visual acuity in • Binocular (Vergence, Acc)
myopic anisometropia of up to 9 • Integration/Stabilization
diopters. Do it all at the same time!
113 114

20. 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!
115 116
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!
117 118
Traditional Therapy Procedures Traditional Therapy Procedures
• Hand-Eye Procedures • Vergence procedures
– mazes – Brock String
– dot to dot – Lifesaver card BI and BO
– cutting – Anaglyph Series (BC920, others)
– coloring • Accommodative Procedures
– filling in O’s – Minus lens dips
– Bunt Ball – Flippers
– Hart Chart
119 120

21. Vergence Procedures Vergence Procedures
Brock String Life Saver Cards
Simple
Inexpensive BO and BI
d
Easy
Good fusion
Effective
Anti-suppression
Inexpensive
Effective
Brock String
121 122
Vergence Procedures Vergence Procedures
Aperture Rule
Fusion Cards
“Flying W”
Random dot
targets Stereoscopes
BC 920, BC 50 Vectograms
Eccentric Circles
Anaglyph
series Vectograms
Aperture Rule
Aperture Rule
123 124
Accommodative Procedures Accommodative Procedures
Rock Card Hart Chart
Flippers the old
standby
Anti-suppression
125 126

22. Vision Therapy Videos Vision Therapy Videos
http://www.youtube.com/watch?v=HtzEHSie-90 http://www.youtube.com/watch?v=fX8mqtgdzgs
127 128
Vision Therapy Videos Vision Therapy Videos
http://www.youtube.com/watch?v=Ui3KTZOdzbo
http://www.youtube.com/watch?v=RTy3o8DwON8 http://www.youtube.com/watch?v=wcVX684r3xQ
129 130
Computer Vision Therapy
Computer Vision Therapy
• Can attack vergence, accommodative, and
oculomotor problems
• Computer based vision therapy program
• Most programs are set up to record patient’s
• Patient can use at home, work, wherever
performance each session
they have access to computer
– Removes the problem of compliance!
• Trains eye movements, vergences,
• Different products on the market
accommodation, and perceptual skills
– Home Therapy System
– Computer Aided Vision Therapy
131 132

23. Why use Computer Aided VT? How do you incorporate
Computer Aided Vision
• “Patients who cannot make a time Therapy in your program?
commitment
• Patient compliance problems • Diagnose the patient!!!
• Insurance or Third Party Problems • Assign a therapy protocol
• It’s Fun! • Computer aided VT in the office
• Schedule follow-up appointments
• Evaluate the patient’s progress/Follow-up
133 134
Computer Aided VT Resources Computer Aided VT Resources
Computer Orthoptics HTS (Home Therapy System)
http://www.homevisiontherapy.com/
135 136
Computer Aided VT Resources Computer Aided VT Resources
137 138

24. Computer Aided VT Resources Computer Aided VT Resources
Computerized Aided Vision Therapy
Gary Vogel, OD, FAAO
http://www.cavt.net/software.html
Available from Bernell 800-348-2225
http://www.bernell.com/
139 140
Computerized Aided Computerized Aided
Vision Therapy Vision Therapy
Module 1 Track and Read Module 2: Visual Therapy
Visual information processing skills
Visual attention/fixation test
Visual reaction time test Left-right warm-ups Directional reactions
Directional questions Random targets
Short term visual memory test
Directional grids Tachistoscopic arrows
Eye tracking test
Satellite commando game
141 142
Computerized Aided Computerized Aided
Vision Therapy Vision Therapy
Module 2: Visual Therapy Module 2: Visual Therapy
Visual Skills Therapy
py Therapy Procedures
py
Visual attention/fixation Tracking with Numbers
Tic-Tac-Toe rotations Spatial Sequencing
Span of recognition Random eye movements
Spatial Patters BPDQ Grids Short term visual memory
Circles, Boxes, Triangles Geo Boards Large angle eye movements
Rotating patterns
143 144

25. Computerized Aided Computerized Aided
Vision Therapy Vision Therapy
Module 2: Visual Therapy Module 2: Visual Therapy
Visual Figure Ground Skills Visual Closure Skills Therapy
Circles & boxes Lines & rectangles
Target counting Character searching Closing on center Closing patterns
Letter locator Dot to dot Letters/numbers dot to dot
Shapes Hidden patterns Closing words Tracking with sequences/words
Verbal saccades Tracking with stories
145 146
Computerized Aided
Vision Therapy Vision Builder
Module 3: Computer Vergences
Ju p vergences (s g e/doub e ta gets)
Jump ve ge ces (single/double targets)
Smooth vergences Pursuit vergences
Life saver drills
Anti-suppression games
147 148
Brainware Safari 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/
http://www.brainwareforyou.com/
149 150

26. Conclusions VT Equipment
• Easy to incorporate VT for BV disorders Use the tools
into your activities discussed
• Monitor the output to check for compliance
and tricks!
You do not need a
• Remember that the key is in diagnosing
patients and follow-up whole room of
VT “stuff”
151 152
WWW Sites for BV/VT BV Organizations
Gemstonevision.Org COVD http://www.covd.org/
OEP http://www.oepf.org//
949-250-8070
AAO BV Section
http://www.aaopt.org/section/bv/index.asp
153 154
301-984-1441
BV Organizations Patient WWW Sites
PAVE/Parents Active 3 D Pictures
for Vision Education http://www.vision3d.com/optical/
http://www.pavevision.org/
htt // ii / index.shtml#stereogram
i d ht l# t
Neuro-Optometric
How Does Binocular Vision Work?
Rehabilitation Association
http://www.vision3d.com/stereo.html
http://www.nora.cc/
155 156

27. Position Statement on VT
Patient WWW Sites
AOA, AAO, COVD many others:
Position Statement on
• http://www.chil
dren-special- Optometric Vision Therapy
needs.org/visio
d / ii
“The American Optometric Association
n_therapy/what affirms its long standing position that
_is_vision_ther optometric vision therapy is effective in the
apy.html treatment of physiological, neuromuscular and
perceptual dysfunctions of the vision
system……..”
157 158
MainosMemos, Facebook, LinkedIn, ICO
My Private Office
159 160
Social/
Professional
Connections
161 162

28. 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