SlideShare ist ein Scribd-Unternehmen logo
1 von 21
Downloaden Sie, um offline zu lesen
To BV or Not to BV:
VT in the
Primary Care Office
23rd Annual Victoria Conference
Delta Ocean Pointe Resort Victoria, BC
Pacific University College of Optometry
July 18th-21, 2013
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
dmaino@ico.edu
Lyons Family Eye Care
Chicago, Il
LyonsFamilyEyeCare.com
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.
4
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
10/121
BV Dx & Tx in the News!!
3D In the News: Update!
11
BV Dx & Tx in the News!!
12
BV Dx & Tx
in the News!!
Sports
Vision !
13
BV Dx & Tx in the News!!
14
BV Dx & Tx in the News!!
15
BV Dx & Tx in the News!!
16
BV Dx & Tx in the News!!
10/97 17
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%
18
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 +
19
Non-strabismic BV disorders
• Convergence Excess: ~6%
• 18 million +
20/121
Non-strabismic BV disorders
• Accommodative disorders: 3-5%
• 15 million +
21
Non-strabismic BV disorders
If any other disease had this
prevalence/incidence, it would be
considered an epidemic…if not a
pandemic!
22
CI on TV
23
NIH NEI and CI
24
Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
25
Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
26
Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
27
Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
28
Screening for BV Dysfunction
20/97 29
Effectiveness of computerized oculomotor vision screening in a
military population: Pilot study José E. Capó-Aponte, OD, PhD, et al.
The number of warfighters affected by blast induced mild traumatic brain injury (mTBI) has
increased considerably in the recent years as a consequence of the current conflicts.
Oculomotor (eye movement) vision problems frequently result from mTBI; however,
conventional oculomotor examinations are time-consuming and can only be performed by an
eye doctor. This limits the number of military personnel that can be evaluated for oculomotor
problems before and after deployment. This study showed that computerized oculomotor
vision screening performed by non-eye-care providers can be an effective means to expedite
the identification and management of oculomotor vision problems in patients with or without
mTBI.
Capó-Aponte JE, Tarbett AK, Urosevich TG, Temme LA, Sanghera NK, Kalich ME.
Effectiveness of computerized oculomotor vision screening in a military population: Pilot study.
J Rehabil Res Dev. 2012;49(9):1377–98. http://dx.doi.org/10.1682/JRRD.2011.07.0128
Comprehensive Eye Examination
Visual Efficiency Evaluation
Strab/Amblyopia Examination
Vision Information Processing
Assessment
Special Testing: Visagraph, TOVA
20/97
PATIENT MAMAGEMENT
30/121
Comprehensive Eye Examination
– History
– VA
– Refraction
– BV (CT, NPC,
Stereo, etc)
– Eye Health
20/97
Do enough testing to meet 3rd party requirements
AND determine if more testing is needed 31
Visual Efficiency Examination:
Basic Tests
• History
(Academics, Sports,
Work, Hobbies)
• COVD Quality of
Life Survey/CISS
• Visual Acuity
20/97 32
Visual Efficiency Examination:
Basic Tests
• Refractive Evaluation
(Objective/Subjective)
20/97 33
Visual Efficiency Examination:
Basic Tests
• Oculomotor
–Cover Test, Hirschberg,
–Kappa, Krimsky, Bruckner
–EOMs
–NPC (with red lens)
20/97 34
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)
35
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
36
Visual Efficiency Examination:
Basic Tests
–NRA/PRA,
Minus Lens
Amplitudes
37
Visual Efficiency Examination:
Basic Tests
–Push Up/Pull Away
Amplitudes, MEM
–Facility
38
Basic tests
• Stereopsis
• Random Dot,
• Stereo Fly
• Less than
70 seconds of arc
39
Basic tests
• Worth 4 Dot
• Fixation Disparity Testing
–Wesson Card,
–Bernell Fixation
Disparity (Associated Phoria),
Disparometer
40/121
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
41
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
42
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
43
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
44
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 45
Accommodative Disorders
• Symptoms: blur,
headache,
aesthenopia, fatigue
when reading,
difficulty changing
focus from one
distance to another
46
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
47
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 48
Other BV Disorders
• Divergence Insufficiency
–Very rare!
–Esophoria greater at distance than near
–Be careful to rule out lateral rectus
palsy!
30/97 49
Strabismus & Amblyopia
3-5% of the population
Tx appropriate at all ages
May do out of office VT
and achieve success!
50/121
Amblyopia
Pathological until
proven otherwise
Infants/Toddlers
Children
Adults
Amblyogenic
Factors
Anisometropia
Bilateral Refractive Error
Strabismus (Constant)
51
Amblyopia
Legal Consultant
Amblyopia
Malpractice case was not because of missing
an eye disease…But rather due to alleged
inappropriate management/treatment
52
Diagnosis &
Treatment
for BV
Disorders
53
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.
54
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.
55
Treatment for BV Disorders
Evidence Based Medicine
Quaid P, Simpson T.Association between reading speed, cycloplegic refractive
error, and oculomotor function in reading disabled children versus controls.
Graefes Arch Clin Exp Ophthalmol. 2013 Jan;251(1):169-87. doi:
10.1007/s00417-012-2135-0. Epub 2012 Aug 29.
The IEP group had significantly greater hyperopia compared to the control
group on cycloplegic examination. Vergence facility was significantly
correlated to (i) reading speed, (ii) number of eye movements made when
reading, and (iii) a standardized symptom scoring system. Vergence facility was
also significantly reduced in the IEP group versus controls. Significant
differences in several other binocular vision related scores were also found.
56
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.
57
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.
58
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.
59
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
60/121
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.
Adult Amblyopia
61
Treatment for BV Disorders
• Treatment modalities
– Lenses
– Prisms
– Vision therapy
• Traditional therapy
• Computer therapy
40/97
62
Lenses as Treatment
Best Rx (clarity, comfort, function)
Refractive Error Amblyopia
Concern
Binocularity
Concerns
Interference
with
Learning
Rx if….
Myopia >5.00D Under correct
eso/Fully
correct exo
Depends
on child’s
age
>5.00D (any age)
>3.00D @>1yr
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
63
Lenses as Treatment
• Best Rx (clarity, comfort,
function)
• Accommodative disorders
– Can prescribe reading only Rx or an
add (I never give R/O, D/O)
• Exodeviations
– Overminusing (DE)
– May not be a first choice. Give add
64
Bifocals for Kids
Bifocal Seg Height
Infants/Toddlers
Pre-schoolers
Bi-sect pupil
65
Bifocals for Kids
Bifocal Seg Height
3-5 Years
Bottom 1/3 of Pupil
66
Bifocals for Kids
Bifocal Seg Height
> 5yrs
Bottom of Pupil
67
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.
68
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.
69
Polycarbonate/Trivex Lenses
70/121
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
71
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
72
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?)
73
Vision Therapy for Amblyopia
• Prescribe Rx
• Implement occlusion therapy
•Implement Atropine therapy
• Active optometric vision therapy
• Monitor
• Change Rx/Tx as needed
74
Period of Sensitivity
vs
Period of Plasticity
75
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.
76
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.
77
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.
78
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.
79
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
80/121
Amblyopia Therapy
What do we know about amblyopia?
– More than decreased VA
– Visual-Spatial affects
– Accommodation
– Hand-eye
– Stereopsis
81
Active Vision Therapy
Hand-eye
Oculomotor
Accommodation
Have child “Do Stuff”
Interact with environment
60/97
82
Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic
amblyopia. EYE. 2004;18(1):109-10
CONCLUSIONS: High anisometropic amblyopia is
challenging to treat. In our study contact
lenses improved visual acuity in myopic
anisometropia of up to 9 dioptres.
83
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!
84
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!
85
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!
86
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!
87
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!
88
Traditional Therapy Procedures
• Hand-Eye Procedures
– mazes
– dot to dot
– cutting
– coloring
– filling in O’s
89
Traditional Therapy Procedures
• Vergence procedures
– Brock String
– Lifesaver card
– Anaglyph Series (BC920, others)
• Accommodative Procedures
– Minus lens dips
– Flippers
– Hart Chart
90
Vergence Procedures
Brock String
Simple
Inexpensive
Easy
Effective
91
Vergence Procedures
Life Saver Cards
BO and BI
Good fusion
Anti-suppression
Inexpensive
Effective
70/97
92
Vergence Procedures
Fusion Cards
Random dot
targets
BC 920, BC 50
Anaglyph series
93
Vergence Procedures
Aperture Rule
“Flying W”
Stereoscopes
94
Accommodative Procedures
Rock Card
Flippers
Anti-suppression
95
Accommodative Procedures
Hart Chart
the old
standby
96
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
97
Computer Vision Therapy
• Patient can use at home, work,
wherever they have access to
computer
• Trains eye movements,
vergences, accommodation,
and perceptual skills
98
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
99
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
100
Computer Aided VT Resources
Neuroscience
Center of
Indianapolis
http://www.neuro
science.cnter.c
om/
101
http://www.jofcr.com/stcds/stcds
.html
Soft Tools
Computer Aided VT Resources
Computer Orthoptics
HTS (Home Therapy System)
http://www.homevisiontherapy.com/
80/97 102
Computer Aided VT Resources
Computerized Aided
Vision Therapy
Gary Vogel, OD, FAAO
Available from Bernell
800-348-2225
http://www.bernell.com/
103
Brainware Safari
http://www.brainwareforyou.com/
104
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/
105
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
106
VT Equipment
Use the tools
discussed
You do not need a
whole room of
VT “stuff”
85/97 107
WWW Sites for BV/VT
Gemstonevision.
Org
108
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 109
BV Organizations
PAVE/Parents Active
for Vision Education
http://www.pave-eye.com/
Neuro-Optometric
Rehabilitation Association
http://www.noravc.com/
110
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
111
Patient WWW Sites
• http://www.chil
dren-special-
needs.org/visio
n_therapy/what
_is_vision_ther
apy.html
90/97
112
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……..”
113
Practice Management
Myths
VT is Too Expensive!
You Can’t Make Money Doing VT!
Which is it? Can’t have it both ways!
114
Practice Management
First
Comprehensive Examination
Then
Visual Efficiency
Strab/Amblyopia
Follow-up
115
Practice Management
All BV Disorders are a
Medical Condition
CI, CE, DI, DE, Pursuit/Saccade Dysfunction
116
Practice Management
Accommodative disorders
tend to be refractive
Accommodative insufficiency, excess, infacility,
instability, etc
95/97
117
Practice Management
Visual Discomfort
is a medical diagnosis
118
119
All Ages Can Benefit….
More Patients
Better Patient Care
Evidenced Based
Do it! 120
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 121

Weitere ähnliche Inhalte

Was ist angesagt?

Visioary ophthalmology tbi presentation 9.7.14
Visioary ophthalmology tbi presentation 9.7.14Visioary ophthalmology tbi presentation 9.7.14
Visioary ophthalmology tbi presentation 9.7.14Visionary Ophthamology
 
Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...
Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...
Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...Dominick Maino
 
Child with Special Needs Part 2
Child with Special Needs   Part 2Child with Special Needs   Part 2
Child with Special Needs Part 2Dominick Maino
 
Improving vision function in the patient with Traumatic Brain Injury
Improving vision function in the patient with Traumatic Brain InjuryImproving vision function in the patient with Traumatic Brain Injury
Improving vision function in the patient with Traumatic Brain InjuryDominick Maino
 
Lecture Handouts: Pediatric Cortical Visual Impairment
Lecture Handouts: Pediatric Cortical Visual ImpairmentLecture Handouts: Pediatric Cortical Visual Impairment
Lecture Handouts: Pediatric Cortical Visual ImpairmentDominick Maino
 
Pallister-Killian Mosaic Syndrome
Pallister-Killian Mosaic SyndromePallister-Killian Mosaic Syndrome
Pallister-Killian Mosaic SyndromeDominick Maino
 
Dr screening training for nurses 7-detecting retinal disease
Dr screening training for nurses   7-detecting retinal diseaseDr screening training for nurses   7-detecting retinal disease
Dr screening training for nurses 7-detecting retinal diseaseRiyad Banayot
 
Acute ocular chemical injury: a descriptive assessment and management review ...
Acute ocular chemical injury: a descriptive assessment and management review ...Acute ocular chemical injury: a descriptive assessment and management review ...
Acute ocular chemical injury: a descriptive assessment and management review ...Riyad Banayot
 
Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...
Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...
Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...Visionary Ophthamology
 
Partnering with the Pediatric Ophthalmology Service: Special Considerations ...
Partnering with the Pediatric Ophthalmology Service:  Special Considerations ...Partnering with the Pediatric Ophthalmology Service:  Special Considerations ...
Partnering with the Pediatric Ophthalmology Service: Special Considerations ...Alvina Pauline Santiago, MD
 
Prescribing spectacles in_children__a_pediatric.9
Prescribing spectacles in_children__a_pediatric.9Prescribing spectacles in_children__a_pediatric.9
Prescribing spectacles in_children__a_pediatric.9Yesenia Castillo Salinas
 
Diagnosis and Management of Special Populations Part II 2010
Diagnosis and Management of Special Populations Part II 2010Diagnosis and Management of Special Populations Part II 2010
Diagnosis and Management of Special Populations Part II 2010Dominick Maino
 
Convergence insufficiency what every physician should know 3.0
Convergence insufficiency  what every physician should know 3.0Convergence insufficiency  what every physician should know 3.0
Convergence insufficiency what every physician should know 3.0Dan Fortenbacher, O.D., FCOVD
 
Lazy Eye, Eye Turns and Other Functional Vision Disorders
Lazy Eye, Eye Turns and Other Functional Vision DisordersLazy Eye, Eye Turns and Other Functional Vision Disorders
Lazy Eye, Eye Turns and Other Functional Vision DisordersDominick Maino
 
Lecture fakulti pendidikan 2011
Lecture fakulti pendidikan 2011Lecture fakulti pendidikan 2011
Lecture fakulti pendidikan 2011mfmy_fahmy
 
Spasm of the_near_reflex_triggered_by_disruption.9
Spasm of the_near_reflex_triggered_by_disruption.9Spasm of the_near_reflex_triggered_by_disruption.9
Spasm of the_near_reflex_triggered_by_disruption.9Yesenia Castillo Salinas
 

Was ist angesagt? (20)

Visioary ophthalmology tbi presentation 9.7.14
Visioary ophthalmology tbi presentation 9.7.14Visioary ophthalmology tbi presentation 9.7.14
Visioary ophthalmology tbi presentation 9.7.14
 
Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...
Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...
Current Clinical Case Reorts & Research You Should Incorporate into Your Mode...
 
Child with Special Needs Part 2
Child with Special Needs   Part 2Child with Special Needs   Part 2
Child with Special Needs Part 2
 
Improving vision function in the patient with Traumatic Brain Injury
Improving vision function in the patient with Traumatic Brain InjuryImproving vision function in the patient with Traumatic Brain Injury
Improving vision function in the patient with Traumatic Brain Injury
 
Lecture Handouts: Pediatric Cortical Visual Impairment
Lecture Handouts: Pediatric Cortical Visual ImpairmentLecture Handouts: Pediatric Cortical Visual Impairment
Lecture Handouts: Pediatric Cortical Visual Impairment
 
Pallister-Killian Mosaic Syndrome
Pallister-Killian Mosaic SyndromePallister-Killian Mosaic Syndrome
Pallister-Killian Mosaic Syndrome
 
051618 #VisionScreening, #upmedwebinars
051618 #VisionScreening, #upmedwebinars051618 #VisionScreening, #upmedwebinars
051618 #VisionScreening, #upmedwebinars
 
Dr screening training for nurses 7-detecting retinal disease
Dr screening training for nurses   7-detecting retinal diseaseDr screening training for nurses   7-detecting retinal disease
Dr screening training for nurses 7-detecting retinal disease
 
Acute ocular chemical injury: a descriptive assessment and management review ...
Acute ocular chemical injury: a descriptive assessment and management review ...Acute ocular chemical injury: a descriptive assessment and management review ...
Acute ocular chemical injury: a descriptive assessment and management review ...
 
2019 Prescribing Eyeglasses in Children
2019 Prescribing Eyeglasses in Children2019 Prescribing Eyeglasses in Children
2019 Prescribing Eyeglasses in Children
 
Vision Deficits Following Traumatic Brain Injury
Vision Deficits Following Traumatic Brain InjuryVision Deficits Following Traumatic Brain Injury
Vision Deficits Following Traumatic Brain Injury
 
Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...
Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...
Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue P...
 
Partnering with the Pediatric Ophthalmology Service: Special Considerations ...
Partnering with the Pediatric Ophthalmology Service:  Special Considerations ...Partnering with the Pediatric Ophthalmology Service:  Special Considerations ...
Partnering with the Pediatric Ophthalmology Service: Special Considerations ...
 
Prescribing spectacles in_children__a_pediatric.9
Prescribing spectacles in_children__a_pediatric.9Prescribing spectacles in_children__a_pediatric.9
Prescribing spectacles in_children__a_pediatric.9
 
Strabismus stdents 2
Strabismus stdents 2Strabismus stdents 2
Strabismus stdents 2
 
Diagnosis and Management of Special Populations Part II 2010
Diagnosis and Management of Special Populations Part II 2010Diagnosis and Management of Special Populations Part II 2010
Diagnosis and Management of Special Populations Part II 2010
 
Convergence insufficiency what every physician should know 3.0
Convergence insufficiency  what every physician should know 3.0Convergence insufficiency  what every physician should know 3.0
Convergence insufficiency what every physician should know 3.0
 
Lazy Eye, Eye Turns and Other Functional Vision Disorders
Lazy Eye, Eye Turns and Other Functional Vision DisordersLazy Eye, Eye Turns and Other Functional Vision Disorders
Lazy Eye, Eye Turns and Other Functional Vision Disorders
 
Lecture fakulti pendidikan 2011
Lecture fakulti pendidikan 2011Lecture fakulti pendidikan 2011
Lecture fakulti pendidikan 2011
 
Spasm of the_near_reflex_triggered_by_disruption.9
Spasm of the_near_reflex_triggered_by_disruption.9Spasm of the_near_reflex_triggered_by_disruption.9
Spasm of the_near_reflex_triggered_by_disruption.9
 

Ähnlich wie To BV or not to BV

Diagnosing Learning Related Vision Problems
Diagnosing Learning Related Vision ProblemsDiagnosing Learning Related Vision Problems
Diagnosing Learning Related Vision ProblemsDominick Maino
 
Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...
Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...
Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...Alvina Pauline Santiago, MD
 
Eye care - Common Eye related Conditions.pptx
Eye care - Common Eye related Conditions.pptxEye care - Common Eye related Conditions.pptx
Eye care - Common Eye related Conditions.pptxOrianaDipak1
 
Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...
Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...
Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...eadvisor
 
What is Convergence Insufficiency?
What is Convergence Insufficiency?What is Convergence Insufficiency?
What is Convergence Insufficiency?Dominick Maino
 
Retinal vein occlusions 3
Retinal vein occlusions 3Retinal vein occlusions 3
Retinal vein occlusions 3Arash Eslami
 
Falls Collaborative Clinical updates
Falls Collaborative Clinical updates Falls Collaborative Clinical updates
Falls Collaborative Clinical updates NHS Improvement
 
Case Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous RetinopathyCase Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous RetinopathyDan Mulder
 
Multifocal Choroiditis
Multifocal ChoroiditisMultifocal Choroiditis
Multifocal Choroiditispinchasmd
 
Strabismus Surgery Outcomes
Strabismus Surgery OutcomesStrabismus Surgery Outcomes
Strabismus Surgery OutcomesDominick Maino
 
How Ptosis Affects Patients
How Ptosis Affects PatientsHow Ptosis Affects Patients
How Ptosis Affects PatientsKristin Oliver
 
Tendonitis Case Studies
Tendonitis Case StudiesTendonitis Case Studies
Tendonitis Case StudiesKarrie Garcia
 
Retina Grand Rounds 2015
Retina Grand Rounds 2015Retina Grand Rounds 2015
Retina Grand Rounds 2015Rick Trevino
 
Orientation,history taking and examinatio.ppt
Orientation,history taking and examinatio.pptOrientation,history taking and examinatio.ppt
Orientation,history taking and examinatio.pptsultanovasits
 
Clinical study of fundal changes in high myopia
Clinical study of fundal changes in high myopiaClinical study of fundal changes in high myopia
Clinical study of fundal changes in high myopiaiosrjce
 
Diagnosing learning related vision problems
Diagnosing learning related vision problemsDiagnosing learning related vision problems
Diagnosing learning related vision problemsDominick Maino
 

Ähnlich wie To BV or not to BV (20)

Diagnosing Learning Related Vision Problems
Diagnosing Learning Related Vision ProblemsDiagnosing Learning Related Vision Problems
Diagnosing Learning Related Vision Problems
 
Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...
Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...
Beyond the screen: caring for our eyes: 2022 kids pandemic eyes for XS Nuvali...
 
Eye care - Common Eye related Conditions.pptx
Eye care - Common Eye related Conditions.pptxEye care - Common Eye related Conditions.pptx
Eye care - Common Eye related Conditions.pptx
 
Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...
Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...
Individuals with Disabilities Service: Overview with emphasis on the NEEI/Per...
 
What is Convergence Insufficiency?
What is Convergence Insufficiency?What is Convergence Insufficiency?
What is Convergence Insufficiency?
 
Retinal vein occlusions 3
Retinal vein occlusions 3Retinal vein occlusions 3
Retinal vein occlusions 3
 
Falls Collaborative Clinical updates
Falls Collaborative Clinical updates Falls Collaborative Clinical updates
Falls Collaborative Clinical updates
 
Screening
ScreeningScreening
Screening
 
Case Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous RetinopathyCase Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous Retinopathy
 
Ocular Disease
Ocular DiseaseOcular Disease
Ocular Disease
 
History taking
History takingHistory taking
History taking
 
Multifocal Choroiditis
Multifocal ChoroiditisMultifocal Choroiditis
Multifocal Choroiditis
 
Strabismus Surgery Outcomes
Strabismus Surgery OutcomesStrabismus Surgery Outcomes
Strabismus Surgery Outcomes
 
How Ptosis Affects Patients
How Ptosis Affects PatientsHow Ptosis Affects Patients
How Ptosis Affects Patients
 
Tendonitis Case Studies
Tendonitis Case StudiesTendonitis Case Studies
Tendonitis Case Studies
 
Retina Rounds
Retina RoundsRetina Rounds
Retina Rounds
 
Retina Grand Rounds 2015
Retina Grand Rounds 2015Retina Grand Rounds 2015
Retina Grand Rounds 2015
 
Orientation,history taking and examinatio.ppt
Orientation,history taking and examinatio.pptOrientation,history taking and examinatio.ppt
Orientation,history taking and examinatio.ppt
 
Clinical study of fundal changes in high myopia
Clinical study of fundal changes in high myopiaClinical study of fundal changes in high myopia
Clinical study of fundal changes in high myopia
 
Diagnosing learning related vision problems
Diagnosing learning related vision problemsDiagnosing learning related vision problems
Diagnosing learning related vision problems
 

Mehr von Dominick Maino

St Bartholomew Choral Music
St Bartholomew Choral MusicSt Bartholomew Choral Music
St Bartholomew Choral MusicDominick Maino
 
Aging Oxidative Stress and Dietary Oxidants
Aging Oxidative Stress and Dietary OxidantsAging Oxidative Stress and Dietary Oxidants
Aging Oxidative Stress and Dietary OxidantsDominick Maino
 
06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into your06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into yourDominick Maino
 
06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into your06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into yourDominick Maino
 
2017 Patients with Special Nedds
2017 Patients with Special  Nedds2017 Patients with Special  Nedds
2017 Patients with Special NeddsDominick Maino
 
Cantonese: Eye Examination
Cantonese: Eye ExaminationCantonese: Eye Examination
Cantonese: Eye ExaminationDominick Maino
 
Optometric Eye Examination in Arabic
Optometric Eye Examination in ArabicOptometric Eye Examination in Arabic
Optometric Eye Examination in ArabicDominick Maino
 
PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...
PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...
PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...Dominick Maino
 
D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16
D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16
D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16Dominick Maino
 
Writing the Perfect Poster Abstract in 20 Minutes or Less
Writing the Perfect Poster Abstract in 20 Minutes or LessWriting the Perfect Poster Abstract in 20 Minutes or Less
Writing the Perfect Poster Abstract in 20 Minutes or LessDominick Maino
 
Pediatric Cortical Visual Impairment
Pediatric Cortical Visual ImpairmentPediatric Cortical Visual Impairment
Pediatric Cortical Visual ImpairmentDominick Maino
 
Evidence-based Information on Nutrition and Non-Traditional Therapy
Evidence-based Information on Nutrition and Non-Traditional TherapyEvidence-based Information on Nutrition and Non-Traditional Therapy
Evidence-based Information on Nutrition and Non-Traditional TherapyDominick Maino
 
A,B,V's of School Performance: Academics, Behavior and Vision
A,B,V's of School Performance: Academics, Behavior and VisionA,B,V's of School Performance: Academics, Behavior and Vision
A,B,V's of School Performance: Academics, Behavior and VisionDominick Maino
 
Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...
Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...
Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...Dominick Maino
 
060915 current research that you should incorporate into your
060915 current research that you should incorporate into your060915 current research that you should incorporate into your
060915 current research that you should incorporate into yourDominick Maino
 
Agenda Driven Research
Agenda Driven ResearchAgenda Driven Research
Agenda Driven ResearchDominick Maino
 
Wolf Hirschhorn Syndrome
 Wolf Hirschhorn Syndrome Wolf Hirschhorn Syndrome
Wolf Hirschhorn SyndromeDominick Maino
 
Dr. Dominick Maino Quoted in AOAFocus Article: Wearable Wonder
Dr. Dominick Maino Quoted in AOAFocus Article: Wearable WonderDr. Dominick Maino Quoted in AOAFocus Article: Wearable Wonder
Dr. Dominick Maino Quoted in AOAFocus Article: Wearable WonderDominick Maino
 
Maino's Christmas Newsletter 2014
Maino's Christmas Newsletter 2014Maino's Christmas Newsletter 2014
Maino's Christmas Newsletter 2014Dominick Maino
 
Pediatric Cortical Visual Impairment: NORA-COVD ICO Lecture
Pediatric Cortical Visual Impairment: NORA-COVD ICO LecturePediatric Cortical Visual Impairment: NORA-COVD ICO Lecture
Pediatric Cortical Visual Impairment: NORA-COVD ICO LectureDominick Maino
 

Mehr von Dominick Maino (20)

St Bartholomew Choral Music
St Bartholomew Choral MusicSt Bartholomew Choral Music
St Bartholomew Choral Music
 
Aging Oxidative Stress and Dietary Oxidants
Aging Oxidative Stress and Dietary OxidantsAging Oxidative Stress and Dietary Oxidants
Aging Oxidative Stress and Dietary Oxidants
 
06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into your06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into your
 
06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into your06 17 current research that you should incorporate into your
06 17 current research that you should incorporate into your
 
2017 Patients with Special Nedds
2017 Patients with Special  Nedds2017 Patients with Special  Nedds
2017 Patients with Special Nedds
 
Cantonese: Eye Examination
Cantonese: Eye ExaminationCantonese: Eye Examination
Cantonese: Eye Examination
 
Optometric Eye Examination in Arabic
Optometric Eye Examination in ArabicOptometric Eye Examination in Arabic
Optometric Eye Examination in Arabic
 
PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...
PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...
PDF Handout: D Maino: Visual Diagnosis and Care of the Patient with Special N...
 
D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16
D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16
D. Maino: Visual Diagnosis and Care of the Patient with Special Needs 06-09-16
 
Writing the Perfect Poster Abstract in 20 Minutes or Less
Writing the Perfect Poster Abstract in 20 Minutes or LessWriting the Perfect Poster Abstract in 20 Minutes or Less
Writing the Perfect Poster Abstract in 20 Minutes or Less
 
Pediatric Cortical Visual Impairment
Pediatric Cortical Visual ImpairmentPediatric Cortical Visual Impairment
Pediatric Cortical Visual Impairment
 
Evidence-based Information on Nutrition and Non-Traditional Therapy
Evidence-based Information on Nutrition and Non-Traditional TherapyEvidence-based Information on Nutrition and Non-Traditional Therapy
Evidence-based Information on Nutrition and Non-Traditional Therapy
 
A,B,V's of School Performance: Academics, Behavior and Vision
A,B,V's of School Performance: Academics, Behavior and VisionA,B,V's of School Performance: Academics, Behavior and Vision
A,B,V's of School Performance: Academics, Behavior and Vision
 
Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...
Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...
Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Speci...
 
060915 current research that you should incorporate into your
060915 current research that you should incorporate into your060915 current research that you should incorporate into your
060915 current research that you should incorporate into your
 
Agenda Driven Research
Agenda Driven ResearchAgenda Driven Research
Agenda Driven Research
 
Wolf Hirschhorn Syndrome
 Wolf Hirschhorn Syndrome Wolf Hirschhorn Syndrome
Wolf Hirschhorn Syndrome
 
Dr. Dominick Maino Quoted in AOAFocus Article: Wearable Wonder
Dr. Dominick Maino Quoted in AOAFocus Article: Wearable WonderDr. Dominick Maino Quoted in AOAFocus Article: Wearable Wonder
Dr. Dominick Maino Quoted in AOAFocus Article: Wearable Wonder
 
Maino's Christmas Newsletter 2014
Maino's Christmas Newsletter 2014Maino's Christmas Newsletter 2014
Maino's Christmas Newsletter 2014
 
Pediatric Cortical Visual Impairment: NORA-COVD ICO Lecture
Pediatric Cortical Visual Impairment: NORA-COVD ICO LecturePediatric Cortical Visual Impairment: NORA-COVD ICO Lecture
Pediatric Cortical Visual Impairment: NORA-COVD ICO Lecture
 

Kürzlich hochgeladen

pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 

Kürzlich hochgeladen (20)

pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 

To BV or not to BV

  • 1. To BV or Not to BV: VT in the Primary Care Office 23rd Annual Victoria Conference Delta Ocean Pointe Resort Victoria, BC Pacific University College of Optometry July 18th-21, 2013 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 dmaino@ico.edu Lyons Family Eye Care Chicago, Il LyonsFamilyEyeCare.com 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. 4 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
  • 2. 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 10/121 BV Dx & Tx in the News!! 3D In the News: Update! 11 BV Dx & Tx in the News!! 12
  • 3. BV Dx & Tx in the News!! Sports Vision ! 13 BV Dx & Tx in the News!! 14 BV Dx & Tx in the News!! 15 BV Dx & Tx in the News!! 16 BV Dx & Tx in the News!! 10/97 17 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% 18
  • 4. 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 + 19 Non-strabismic BV disorders • Convergence Excess: ~6% • 18 million + 20/121 Non-strabismic BV disorders • Accommodative disorders: 3-5% • 15 million + 21 Non-strabismic BV disorders If any other disease had this prevalence/incidence, it would be considered an epidemic…if not a pandemic! 22 CI on TV 23 NIH NEI and CI 24
  • 5. Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 25 Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 26 Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 27 Subjective Complaints of Patients with BV Disorders • Blur • Headache • Aesthenopia • Diplopia • These complaints are usually associated with near work 28 Screening for BV Dysfunction 20/97 29 Effectiveness of computerized oculomotor vision screening in a military population: Pilot study José E. Capó-Aponte, OD, PhD, et al. The number of warfighters affected by blast induced mild traumatic brain injury (mTBI) has increased considerably in the recent years as a consequence of the current conflicts. Oculomotor (eye movement) vision problems frequently result from mTBI; however, conventional oculomotor examinations are time-consuming and can only be performed by an eye doctor. This limits the number of military personnel that can be evaluated for oculomotor problems before and after deployment. This study showed that computerized oculomotor vision screening performed by non-eye-care providers can be an effective means to expedite the identification and management of oculomotor vision problems in patients with or without mTBI. Capó-Aponte JE, Tarbett AK, Urosevich TG, Temme LA, Sanghera NK, Kalich ME. Effectiveness of computerized oculomotor vision screening in a military population: Pilot study. J Rehabil Res Dev. 2012;49(9):1377–98. http://dx.doi.org/10.1682/JRRD.2011.07.0128 Comprehensive Eye Examination Visual Efficiency Evaluation Strab/Amblyopia Examination Vision Information Processing Assessment Special Testing: Visagraph, TOVA 20/97 PATIENT MAMAGEMENT 30/121
  • 6. Comprehensive Eye Examination – History – VA – Refraction – BV (CT, NPC, Stereo, etc) – Eye Health 20/97 Do enough testing to meet 3rd party requirements AND determine if more testing is needed 31 Visual Efficiency Examination: Basic Tests • History (Academics, Sports, Work, Hobbies) • COVD Quality of Life Survey/CISS • Visual Acuity 20/97 32 Visual Efficiency Examination: Basic Tests • Refractive Evaluation (Objective/Subjective) 20/97 33 Visual Efficiency Examination: Basic Tests • Oculomotor –Cover Test, Hirschberg, –Kappa, Krimsky, Bruckner –EOMs –NPC (with red lens) 20/97 34 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) 35 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 36
  • 7. Visual Efficiency Examination: Basic Tests –NRA/PRA, Minus Lens Amplitudes 37 Visual Efficiency Examination: Basic Tests –Push Up/Pull Away Amplitudes, MEM –Facility 38 Basic tests • Stereopsis • Random Dot, • Stereo Fly • Less than 70 seconds of arc 39 Basic tests • Worth 4 Dot • Fixation Disparity Testing –Wesson Card, –Bernell Fixation Disparity (Associated Phoria), Disparometer 40/121 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 41 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 42
  • 8. 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 43 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 44 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 45 Accommodative Disorders • Symptoms: blur, headache, aesthenopia, fatigue when reading, difficulty changing focus from one distance to another 46 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 47 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 48
  • 9. Other BV Disorders • Divergence Insufficiency –Very rare! –Esophoria greater at distance than near –Be careful to rule out lateral rectus palsy! 30/97 49 Strabismus & Amblyopia 3-5% of the population Tx appropriate at all ages May do out of office VT and achieve success! 50/121 Amblyopia Pathological until proven otherwise Infants/Toddlers Children Adults Amblyogenic Factors Anisometropia Bilateral Refractive Error Strabismus (Constant) 51 Amblyopia Legal Consultant Amblyopia Malpractice case was not because of missing an eye disease…But rather due to alleged inappropriate management/treatment 52 Diagnosis & Treatment for BV Disorders 53 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. 54
  • 10. 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. 55 Treatment for BV Disorders Evidence Based Medicine Quaid P, Simpson T.Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls. Graefes Arch Clin Exp Ophthalmol. 2013 Jan;251(1):169-87. doi: 10.1007/s00417-012-2135-0. Epub 2012 Aug 29. The IEP group had significantly greater hyperopia compared to the control group on cycloplegic examination. Vergence facility was significantly correlated to (i) reading speed, (ii) number of eye movements made when reading, and (iii) a standardized symptom scoring system. Vergence facility was also significantly reduced in the IEP group versus controls. Significant differences in several other binocular vision related scores were also found. 56 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. 57 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. 58 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. 59 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 60/121
  • 11. 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. Adult Amblyopia 61 Treatment for BV Disorders • Treatment modalities – Lenses – Prisms – Vision therapy • Traditional therapy • Computer therapy 40/97 62 Lenses as Treatment Best Rx (clarity, comfort, function) Refractive Error Amblyopia Concern Binocularity Concerns Interference with Learning Rx if…. Myopia >5.00D Under correct eso/Fully correct exo Depends on child’s age >5.00D (any age) >3.00D @>1yr 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 63 Lenses as Treatment • Best Rx (clarity, comfort, function) • Accommodative disorders – Can prescribe reading only Rx or an add (I never give R/O, D/O) • Exodeviations – Overminusing (DE) – May not be a first choice. Give add 64 Bifocals for Kids Bifocal Seg Height Infants/Toddlers Pre-schoolers Bi-sect pupil 65 Bifocals for Kids Bifocal Seg Height 3-5 Years Bottom 1/3 of Pupil 66
  • 12. Bifocals for Kids Bifocal Seg Height > 5yrs Bottom of Pupil 67 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. 68 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. 69 Polycarbonate/Trivex Lenses 70/121 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 71 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 72
  • 13. 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?) 73 Vision Therapy for Amblyopia • Prescribe Rx • Implement occlusion therapy •Implement Atropine therapy • Active optometric vision therapy • Monitor • Change Rx/Tx as needed 74 Period of Sensitivity vs Period of Plasticity 75 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. 76 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. 77 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. 78
  • 14. 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. 79 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 80/121 Amblyopia Therapy What do we know about amblyopia? – More than decreased VA – Visual-Spatial affects – Accommodation – Hand-eye – Stereopsis 81 Active Vision Therapy Hand-eye Oculomotor Accommodation Have child “Do Stuff” Interact with environment 60/97 82 Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10 CONCLUSIONS: High anisometropic amblyopia is challenging to treat. In our study contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres. 83 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! 84
  • 15. 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! 85 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! 86 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! 87 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! 88 Traditional Therapy Procedures • Hand-Eye Procedures – mazes – dot to dot – cutting – coloring – filling in O’s 89 Traditional Therapy Procedures • Vergence procedures – Brock String – Lifesaver card – Anaglyph Series (BC920, others) • Accommodative Procedures – Minus lens dips – Flippers – Hart Chart 90
  • 16. Vergence Procedures Brock String Simple Inexpensive Easy Effective 91 Vergence Procedures Life Saver Cards BO and BI Good fusion Anti-suppression Inexpensive Effective 70/97 92 Vergence Procedures Fusion Cards Random dot targets BC 920, BC 50 Anaglyph series 93 Vergence Procedures Aperture Rule “Flying W” Stereoscopes 94 Accommodative Procedures Rock Card Flippers Anti-suppression 95 Accommodative Procedures Hart Chart the old standby 96
  • 17. 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 97 Computer Vision Therapy • Patient can use at home, work, wherever they have access to computer • Trains eye movements, vergences, accommodation, and perceptual skills 98 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 99 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 100 Computer Aided VT Resources Neuroscience Center of Indianapolis http://www.neuro science.cnter.c om/ 101 http://www.jofcr.com/stcds/stcds .html Soft Tools Computer Aided VT Resources Computer Orthoptics HTS (Home Therapy System) http://www.homevisiontherapy.com/ 80/97 102
  • 18. Computer Aided VT Resources Computerized Aided Vision Therapy Gary Vogel, OD, FAAO Available from Bernell 800-348-2225 http://www.bernell.com/ 103 Brainware Safari http://www.brainwareforyou.com/ 104 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/ 105 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 106 VT Equipment Use the tools discussed You do not need a whole room of VT “stuff” 85/97 107 WWW Sites for BV/VT Gemstonevision. Org 108
  • 19. 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 109 BV Organizations PAVE/Parents Active for Vision Education http://www.pave-eye.com/ Neuro-Optometric Rehabilitation Association http://www.noravc.com/ 110 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 111 Patient WWW Sites • http://www.chil dren-special- needs.org/visio n_therapy/what _is_vision_ther apy.html 90/97 112 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……..” 113 Practice Management Myths VT is Too Expensive! You Can’t Make Money Doing VT! Which is it? Can’t have it both ways! 114
  • 20. Practice Management First Comprehensive Examination Then Visual Efficiency Strab/Amblyopia Follow-up 115 Practice Management All BV Disorders are a Medical Condition CI, CE, DI, DE, Pursuit/Saccade Dysfunction 116 Practice Management Accommodative disorders tend to be refractive Accommodative insufficiency, excess, infacility, instability, etc 95/97 117 Practice Management Visual Discomfort is a medical diagnosis 118 119 All Ages Can Benefit…. More Patients Better Patient Care Evidenced Based Do it! 120
  • 21. 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 121