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.
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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
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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
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Executive Summary
• Our patients are in pain
• Proven examination techniques
available
• Proven intervention/therapy
available
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Executive Summary
• The myths of OVT wrong
• Expand your patient base
• Be unique
• Offer more
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10/121
BV Dx & Tx in the News!!
3D In the News: Update!
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BV Dx & Tx in the News!!
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3. BV Dx & Tx
in the News!!
Sports
Vision !
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BV Dx & Tx in the News!!
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BV Dx & Tx in the News!!
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BV Dx & Tx in the News!!
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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%
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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 +
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Non-strabismic BV disorders
• Convergence Excess: ~6%
• 18 million +
20/121
Non-strabismic BV disorders
• Accommodative disorders: 3-5%
• 15 million +
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Non-strabismic BV disorders
If any other disease had this
prevalence/incidence, it would be
considered an epidemic…if not a
pandemic!
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CI on TV
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NIH NEI and CI
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5. Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
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Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
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Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
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Subjective Complaints of
Patients with BV Disorders
• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work
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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
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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)
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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
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7. Visual Efficiency Examination:
Basic Tests
–NRA/PRA,
Minus Lens
Amplitudes
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Visual Efficiency Examination:
Basic Tests
–Push Up/Pull Away
Amplitudes, MEM
–Facility
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Basic tests
• Stereopsis
• Random Dot,
• Stereo Fly
• Less than
70 seconds of arc
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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
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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
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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
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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
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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
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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
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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)
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Amblyopia
Legal Consultant
Amblyopia
Malpractice case was not because of missing
an eye disease…But rather due to alleged
inappropriate management/treatment
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Diagnosis &
Treatment
for BV
Disorders
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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.
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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.
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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.
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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.
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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.
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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.
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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
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Treatment for BV Disorders
• Treatment modalities
– Lenses
– Prisms
– Vision therapy
• Traditional therapy
• Computer therapy
40/97
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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
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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
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Bifocals for Kids
Bifocal Seg Height
Infants/Toddlers
Pre-schoolers
Bi-sect pupil
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Bifocals for Kids
Bifocal Seg Height
3-5 Years
Bottom 1/3 of Pupil
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12. Bifocals for Kids
Bifocal Seg Height
> 5yrs
Bottom of Pupil
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Bifocals for Myopia Progression
Gwiazda JE, Hyman L, Norton TT, Hussein ME,
Marsh-Tootle W, Manny R, Wang Y, Everett D;
COMET Grouup.
Accommodation and related risk factors associated
with myopia progression and their interaction with
treatment in COMET children.
Invest Ophthalmol Vis Sci. 2004 Jul;45(7):2143-
51.
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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.
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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.
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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.
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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
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Active Vision Therapy
Hand-eye
Oculomotor
Accommodation
Have child “Do Stuff”
Interact with environment
60/97
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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!
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Traditional Therapy Procedures
• Hand-Eye Procedures
– mazes
– dot to dot
– cutting
– coloring
– filling in O’s
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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