Course given at the AOA meet

1. To BV or Not to BV:
That is No Longer the
Question,
But Rather the Answer!

2. Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor, Pediatrics/Binocular Vision
Illinois Eye Institute
Illinois College of Optometry
Chicago, Il
Lyons Family Eye Care
Chicago, Il

3. To BV or Not to BV: That is No Longer the Question,
But Rather the Answer!
• ..Whether 'tis nobler in the mind to suffer the slings and
arrows of outrageous economics, or to take arms against a
sea of troubles with binocular vision and optometric vision
therapy. To grunt and sweat under a weary life, But that
the dread of something unknown....the undiscovered
country of BV and VT whose bourn all travelers prosper,
doth not puzzle the will and makes us rather bear those
joys we have...than those ills of 3rd party payers that we
know not of? (With apologies to The Bard). This course
reviews the diagnostic and evidence-based therapeutic
procedures the primary care optometrist can use to
improve patient care while supporting the fiscal stability of
their practice.

5. Executive Summary
• Binocular vision in the news
• 3D Vision Syndrome in the news
• High incidence of BV problems
• Evidence based medicine/research
supports optometric vision therapy

6. Executive Summary
• Amblyopia can be treated at any age
• Learning related vision problems
optometric intervention supported by
research
• Attention and binocular vision
problems related

7. Executive Summary
• Our patients are in pain
• Proven examination techniques
available
• Proven intervention/therapy
available

8. Executive Summary
• The myths of OVT wrong
• Expand your patient base
• Be unique
• Offer more

9. BV Dx & Tx in the News!!

10. BV Dx & Tx in the News!!

11. BV Dx & Tx in the News!!

12. BV Dx & Tx in the News!!
10/97

13. Non-strabismic BV disorders
Prevalence/Incidence
• Convergence Insufficiency: 1.3% to 37% of
the population; most report 3-5%
• Convergence Excess: ~6%
• Accommodative disorders: 3-5%

14. Non-strabismic BV disorders
• Convergence Insufficiency: 1.3% to 37% of
the population; most report 3-5%
• 309,000,000 people in USA (2010 Census)
at 5% = 15 million +

15. Non-strabismic BV disorders
• Convergence Excess: ~6%
• 18 million +

16. Non-strabismic BV disorders
• Accommodative disorders: 3-5%
• 15 million +

17. Non-strabismic BV disorders
• If any other disease had this
prevalence, it would be
considered an epidemic…if
not a pandemic!

18. Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work

19. Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work

20. Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work

21. Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work

22. Visual Efficiency Examination:
Basic Tests
• History
• Visual Acuity
20/97

23. Visual Efficiency Examination:
Basic Tests
• Refractive Evaluation
(Objective/Subjective)
20/97

24. Visual Efficiency Examination:
Basic Tests
• Oculomotor
– Cover Test, Hirschberg,
– Kappa, Krimsky, Bruckner
– EOMs
– NPC (with red lens)
20/97

25. Visual Efficiency Examination:
Basic Tests
• Heterophoria
• Vergences
–Sheard’s criteria
• Need twice your phoria in reserve
(10 pd exophore at near needs
20 pd BO reserves)

26. Visual Efficiency Examination:
Basic Tests
• Accommodative Tests
–Minimum amplitude =
15 - (0.25) age
• So a 20 year old should have at
least 10 diopters of
accommodation

27. Visual Efficiency Examination:
Basic Tests
–NRA/PRA,
Minus Lens
Amplitudes

28. Visual Efficiency Examination:
Basic Tests
–Push Up/Pull Away
Amplitudes, MEM
–Facility

29. Basic tests
• Stereopsis
• Random Dot,
• Stereo Fly
• Less than
70 seconds of arc

30. Basic tests
• Worth 4 Dot
• Fixation Disparity Testing
– Wesson Card,
– Bernell Fixation
Disparity (Associated Phoria),
Disparometer

31. 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

32. 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

33. 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

34. 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

35. 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

36. Accommodative Disorders
• Symptoms: blur,
headache,
aesthenopia, fatigue
when reading,
difficulty changing
focus from one
distance to another

37. 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

38. Other BV Disorders
• Divergence Excess
– Prevalence of ~0.5 to 4%
– Exophoria greater at distance than
near
– Frequently first discovered in grade
school
30/97

39. Other BV Disorders
• Divergence Insufficiency
– Very rare!
– Esophoria greater at distance than near
– Be careful to rule out lateral rectus
palsy!
30/97

40. Strabismus & Amblyopia
3-5% of the population
Tx appropriate at all ages
May do out of office VT
and achieve success!

41. Amblyopia
Pathological until Amblyogenic
proven otherwise Factors
Infants/Toddlers Anisometropia
Young Children Bilateral Refractive Error
Busy Adults Strabismus (Constant)

42. Amblyopia
Legal Consultant
Amblyopia
Malpractice case was not because of missing
an eye disease…But rather due to alleged
inappropriate management/treatment

43. 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.

44. 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.

45. 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.

46. 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.

47. 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.

48. 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

49. Adult Amblyopia
Levi DM. Prentice award lecture 2011: removing the
brakes on plasticity in the amblyopic brain.
Optom Vis Sci. 2012 Jun;89(6):827-38.
Video-game play induces plasticity in the visual system of
adults with amblyopia.
Li RW, Ngo C, Nguyen J, Levi DM.
PLoS Biol. 2011 Aug;9(8):e1001135. Epub 2011 Aug 30.
Prolonged perceptual learning of positional acuity in adult
amblyopia: perceptual template retuning dynamics.
Li RW, Klein SA, Levi DM.
J Neurosci. 2008 Dec 24;28(52):14223-9.

50. Treatment for BV Disorders
• Treatment modalities
– Lenses
– Prisms
– Vision therapy
• Traditional therapy
• Computer therapy
40/97

51. 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

52. 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

53. Bifocals for Kids
Bifocal Seg Height
Infants/Toddlers
Pre-schoolers
Bi-sect pupil

54. Bifocals for Kids
Bifocal Seg Height
3-5 Years
Bottom 1/3 of Pupil

55. Bifocals for Kids
Bifocal Seg Height
> 5yrs
Bottom of Pupil

56. 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.

57. Bifocals for Myopia Progression
PALs were effective in slowing progression in these
children, with statistically significant 3-year
treatment effects. 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.

58. Polycarbonate/Trivex Lenses

59. 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

60. Optometric 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
50/97

61. 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?)

62. Vision Therapy for Amblyopia
• Prescribe Rx
• Implement occlusion therapy
• Active optometric vision therapy
• Monitor
• Change Rx/Tx as needed

63. Period of Sensitivity
vs
Period of Plasticity

64. 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.

65. Atropine
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.

66. 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.

67. Atropine
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.

68. 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

69. Amblyopia Therapy
What do we know about amblyopia?
– More than decreased VA
– Visual-Spatial affects
– Accommodation
– Hand-eye
– Stereopsis

70. Active Vision Therapy
Hand-eye
Oculomotor
Accommodation
Have child “Do Stuff”
Interact with environment
60/97

71. Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic
amblyopia. EYE. 2004;18(1):109-10
High anisometropic amblyopia is
CONCLUSIONS:
challenging to treat. In our study contact
lenses improved visual acuity in myopic
anisometropia of up to 9 dioptres.

72. 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!

73. 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!

74. 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!

75. 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!

76. 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!

77. Traditional Therapy Procedures
• Hand-Eye Procedures
– mazes
– dot to dot
– cutting
– coloring
– filling in O’s

78. Traditional Therapy Procedures
• Vergence procedures
– Brock String
– Lifesaver card
– Anaglyph Series (BC920, others)
• Accommodative Procedures
– Minus lens dips
– Flippers
– Hart Chart

79. Vergence Procedures
Brock String
Simple
Inexpensive
Easy
Effective

80. Vergence Procedures
Life Saver Cards
BO and BI
Good fusion
Anti-suppression
Inexpensive
Effective
70/97

81. Vergence Procedures
Fusion Cards
Random dot
targets
BC 920, BC 50
Anaglyph series

82. Vergence Procedures
Aperture Rule
“Flying W”
Stereoscopes

83. Accommodative Procedures
Rock Card
Flippers
Anti-suppression

84. Accommodative Procedures
Hart Chart
the old
standby

85. 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

86. Computer Vision Therapy
• Patient can use at home, work,
wherever they have access to
computer
• Trains eye movements,
vergences, accommodation,
and perceptual skills

87. 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

88. 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

89. Computer Aided VT Resources
Neuroscience Center of Indianapolis
http://www.neuroscience.cnter.com/

90. Computer Aided VT Resources
Computer Orthoptics
HTS (Home Therapy System)
http://www.homevisiontherapy.com/
80/97

91. Computer Aided VT Resources
Computerized Aided
Vision Therapy
Gary Vogel, OD, FAAO
Available from Bernell
800-348-2225
http://www.bernell.com/

92. Brainware Safari
http://www.brainwareforyou.com/

93. 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/

94. 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

95. VT Equipment
Use the tools
discussed
You do not need a
whole room of
VT “stuff”
85/97

96. WWW Sites for BV/VT
Gemstonevision.
Org

97. 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

98. BV Organizations
PAVE/Parents Active
for Vision Education
http://www.pave-eye.com/
Neuro-Optometric
Rehabilitation Association
http://www.noravc.com/

99. 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

100. Patient WWW Sites
• http://www.chil
dren-special-
needs.org/visio
n_therapy/what
_is_vision_ther
apy.html
90/97

101. 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……..”

102. Practice Management
Myths
VT is Too Expensive!
You Can’t Make Money Doing VT!
Which is it? Can’t have it both ways!

103. Practice Management
First
Comprehensive Examination
Then
Visual Efficiency
Strab/Amblyopia
Follow-up

104. Practice Management
All BV Disorders are a
Medical Condition
CI, CE, DI, DE, Pursuit/Saccade Dysfunction

105. Practice Management
Accommodative disorders
tend to be refractive
Accommodative insufficiency, excess, infacility,
instability, etc
95/97

106. Practice Management
Visual Discomfort
is a medical diagnosis

108. All Ages Can Benefit….
More Patients
Better Patient Care
Evidenced Based
Do it!

109. 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 773-935-2020
MainosMemos.com
dmaino@ico.edu
www.LyonsFamilyEyeCare.com
www.ico.edu