This is a recent article I wrote for the Review of Optometry. They haven't made this available online just yet even though the hard copy just arrived in my box. So I thought I'd share it with you. If you attended by lecture at the American Academy of Optometry or are going to attend my lecture at the Vision Institute of Canada, this paper is a valuable adjuct to my presentation.

1. 3-D is not just hype. It can help you diagnose binocular vision disorders and build
your practice. You can even help p atients overcome their problem s with 3-D viewing.
By Dominick M. Maino, 0.0., M.Ed.
W
hy is there such Logie Ba ird, while the
an incredible 1950s ushered in the
interest in 3-D first Golden Age of
movies, televi­ commercially success­
sion, video games and the ful and popular 3-D
use of 3-D technology in the movies (such as "Bwana
classroom? Every time you Devil" and "House of
pick up a newspaper, read a Wax").
magazine or a bl og, surf the Thirty years later,
Internet or listen to the news, another smaller 3-D
you see stories about simulated the most important ques- boom appe.ued which
3-D. What's aU the hype about? Is tions for the optometrist is: Ca n we was initiated by IivlAX.
it rea lly hype or something more improve the actual user of 3-D con­ Unfortunately, there were many
important to your patients and tent so that the experience can be difficulties with this method of pro­
your practice? better appreciated, no matter their ducing 3-D viewing because of the
Can we improve the entertain­ age or the type of simulated 3-D large size and unusual dimensions
ment value of 3-D movies for the content experienced? of the theater screen needed. l
movie-going audience? Can we The answer is, of course, yes. As the history of 3-D technol­
make the extra cos t of buying 3-D ogy moved into the present day,
televisions worthwhile, even for 3-~ Through the Years "Avatar" (2009) could be noted as
those who now have headaches 3-D viewing and its relation bringing the next golden age of 3-D
when they watch 3-D program­ to binocular vision is not a new to the masses. In just the past few
ming? And, what can we do for phenomenon. Thanks to Charles years we've witnessed a boom in
those children wbo cannot appreci­ Wheatstone and his stereoscope (in movies, telev ision, videogames and
ate the sense of depth in 3-D video the 1830s) and the soon-to-follow other media depicted in 3-D.
games or bene fit from the 3-D stereopticon invented by Oliver It should be no surprise then that
classroom educational experience? Wendell Holmes (1862), many the events that soon followed this
Can we ensure that they do not could enjoy this new form of 3-D current explosion of interest in 3-D
miss out on the fun and improved entertainm ent. should include the Ame rican O pto­
academic learning environment? In more modern times, the first metric Association and an industry
When it comes to 3-D viewing stereoscopic 3-D television was group called the 3D@Home Con­
and the patients we serve, one of created in the 1920s by Charles sortium signing a memorandum of
54 REVIEW OF OP TOMETRY O,:TOSfH 15 2011

2. Make 3-0 Pop Up in Your Prce understa nding vbjch ~tated their
With the unending attention centered on 3-D movies, 3-D televisions, 3-D video games, intent to hare da ta an d joi nt ly p ro­
and 3-D in the cfassroom, your office should take advantage of the educational and mar­ mote vision healrh urili.7i n~' tereo­
keting possibilities. Your existing and potential patients are aware of many of the issues scopic 3-D d isplays.2 Borb [he AOA
surrounding simulated 3-D viewing, but have you made them knowledgeable about the an d 3D@Home ha ve joined forces
services you offer so that they can enjoy the digital dazzle associated with this new tech­ by collaborating o n a new enrure:
nology? 3deyehealrh.oq;.
Here's how:
• Offer a seminar about 3-D in your office. Use this article or other resources to Creating 3-~
help tell your patients how simulated 3-D is produced and why some individuals have As every optometrist kn ws, the
problems associated with 3-D Vision Syndrome. Use prism to make individuals in the audi­ creation of simu lated 3-D conte nt
ence diplopic. Use the Brock string to see how many in the audience have binocular vision requires the input of one image into
dysfunctions-l did this at the 2011 Consumer Electronics Show and the response was the right eye and 3.nother si milar
astounding! [Watch the video at httn:llmamosmemos.blogspolcoml2011J04/dr-domiOlck­ but laterally disp laced image into
maino-at·consumer.html.j the other eye. W hen rJ1e brain
• Set up a Google Alert search on 3-D. Find all the media topics and post links on your receives the two images, fUSion
office webpage. Also post these links with commentary on your blog, Facebook page and occurs and a sense of depth is cre­
Linkedln page. ated. Whcn optomctric visiun
• Let your patients know you can diagnose and treat or refer for treatment those thera py i ~ uscd to trcat those with
with 3-D Vision Syndrome. binocul a r vis io n dysfuncti n, thi ~ i
• Obtain copies of "3-D in the Classroom See Well, typically done by havi ng the patient
Learn Well" from the AOA and send it to the schools in wear anaglyph (red/green or rcd/
your area with compliments from your office. Put links on blue) gbsses, p( la roid glasses, or
your office web page and social media sites to this document by synchronIzing the timing of thc
and send email toalltheteachers.principals. school admin­ image to be received by eac h eye in
istrators and parents you know. (Go to 3deyeheallh.org for such a way sO that only one cye secs
more information.) an image a t any me timc. T his is
• Display 3-D art, movie posters and photographs in also true for m ost of the 3-D con­
your office. (See the astounding work of Almont Green at tent our patients view commercially.
a1montgreen.com. He creates great 3-D photographic art. There are several ty pes of glasses
There are also 3-D movie posters available from www.all­ that consumers can I I e to expe­
oosters.com!·sV3-0-Movie-Posters c118624 .hlm, while rience simulated 3- ~. T hey arc
vintage 3·D movie posters can be found at www.3dstereo. catego rized as pa s ivc polarized or
comlviewmaster/3dposters.html.) activ sh uttcr. ( 1 here is als() a yvay
• Offer 3-D glasses with your patients' prescrip­ to create 3-D withou t t be nt ed for
tion in them. Samsung displayed a number of active shutter prescription ready glasses at glasse , s uch as w ith the Nimendo
the 2011 Consumer Electronics 3-DS or the photograp hic art o f
Show. Other manufacturers offer Al mo nt G reen, but I' ll limit the dis­
prescription-ready glasses as cussion to the passive polarized and
well (such as those by Marchon, active shu tter gla se .3-4)
which now offers Marchon 3-D Passive po larized glasse are
glasses and even 3-D clip-ons, either linearl y or cir ularly p o lar­
www.marchon.comIM3D. and ized . Linear p ,I ri zed -D t>la . e '
G unnar Optiks, www.gunoars. w ork with th e older Stereo p roj ec­
com!shoolPremium"30-EyeweaO. Gunnar Opliks Anime 3-D glasses tors, Stereo Jet prints, and m ode rn
Remember that 3-D TV glasses projecto r systems wi th li near p olar­
only work with specified televisions. Make sure you mention this to your patients so they izers. If Y OLl use li near polarized
know that a new pair of glasses may be necessary if they buy a different TV. gLasses, yo u ca nno t turn or til t your
• Make your own 3-D art and photographs and display them in your office head witho m 10 ing the 3-D effect.
(www.3d-lmage.netl. Cir cular polarized glasses a ll ow
you more leeway in terms o f head
56 REVI EW OF OPTOMETRY OCfOSEI1 15 ,2011

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Most 3-D movies use various polarizing techniques,
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The most frequently used technologies for 3-D
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Although the technology to produce 3-D viewing
is constantly being improved, not everyone is able to
experience and enjoy simulated 3-D because of vision
problems tl1at cause headaches, nausea, diplopia and
other symptoms. This is not only true for children but
also for adults. 6
According to the American Optometric Associa­
tion's 2011 American Eye-Q survey, parents are
concerned about the possible detrimental effects of
3-D viewing. Fifty-three percent of respondents with
children 18 or younger believe that 3-D, vie'vving is
harmful to a child's vision. 7 However, the AOA and
several other organizations note that there is currently
no research to support the belief that 3-D viewing is
harmful to a child's vision.
What the primary care optometrist needs to do is
improve the patient's binocular vision skiLls. This will
create a better 3-D viewing audience that can partici­
pate in an enhanced and symptom free 3-D experi­
ence. The first step to making this happen is to use
all the resources available to you to get the word out
about how optometry can help make the 3-D viewing
experience more enjoyable. This will enable you to
reach those patients most in need.

4. In order to assist you in getting ing binocular vision simply won't any binocular vision problems pres­
the word o ut abou t what optom­ see 3-D. Whil e this doesn't pose ent to determine if your patient has
etry can do to improve the 3-D any problem viewing the screen, 3-D vision syndrome (see "Diag­
viewing experience, the AOA, it certainly significantly detracts nosing 3-D Vision Syndrorne,"
3D@Home Co nso rtium a nd 3deye­ from the enj oyment most experi­ beloW).9-1r 3-D vision syndrome
health. o rg havE' come together to let ence while viewing 3-D content and (3DYS) is comprised of a group of
the public know about "The 3Ds of ma kes spending the extra money sym ptoms that collectively indicate
3-D Yi ewi ng": for the 3-D experience worthless. the presence of a functiona l vision
• Disco mfort: Beca use 3-D view­ This can, however, serve as a pub­ disorder which adversely affects the
ing is based on the eyes converging lic hea lth " vision screening" that enjoyment level of watching 3-D
in front of or beyond the screen, something is abnormal with the content. 3DVS symptoms include,
viewing 3-D images can potentiall y viewer's vision. but a re not limited to as thenopia ,
create eyestrain and headaches. Although not sta ted directly, the headaches, blurred vision, eye­
strain, diplopia, dizziness/nausea
Diagnosing 3~D Vision Syndrome and vision-induced motion sickness
During the following elements of the examination, consider these factors if you suspect 3-D after watching a 3-D movie, view­
vision syndrome. ing 3-D television programming,
• Case history: Always ask if your patient has seen a 3-D movie and experienced participating in a 3-D classroom
asthenopia, headaches, blurred vision, eyestrain, diplopia, dizziness/nausea and/or vision­ educational activity or after pla ying
induced motion sickness. If they have never seen a 3-D movie, ask why not. The answer a 3-D video ga me. 1 2
may also suggest vision problems are present. While we've known for som e
• Visual acuity: If accommodation is affected, visual acuity may vary. Any amblyopia time that 3-D viewing can cause
will disrupt 3-D viewing. vision problems to manifest,
• Entrance tests: Stereopsis is usually reduced and suppression can occur. research is only now beginning
• Oculomotor assessment: Cover test, near point of convergence, Hirschberg, Angle to determine which functio nal or
Kappa and Bruckner tests all can indicate a binocular vision problem. group of functional vision disorders
• Refractive error. The objective (retinoscopy) and subjective assessment of refractive are involved in causing the 3 DYS­
error can give variable results. The patient may not be able to give a clear, unambiguous associated symptoms. IJ- 1 One or
5
end point during the manifest subjective assessment procedure. more papers suggest that the symp­
• PhoriaNergence: Both distance and near heterophoria findings, as well as positive toms produced are ca used by:1 6 1 S
and the negative fusional vergence tests, can indicate the presence of afusional vergence • Excessive demands placed upon
anomaly. the linkage of accommoda tion-con­
• Accommodation: Negative and relative accommodation, accommodative facility find­ vergence by viewing fast-moving
ings and the monocular estimation method (MEM dynamic retinoscopy), will give high or 3-D images .
low, inconsistent or variable results. • Spatial and temporal incon ­
• Ocular health: Eye health will usually be unremarkable. sistencies created by 3-D artifacts
from insufficient depth information.
For iolonnatWn on how 1 perform ttlestl l~ts. see
0
• 3chl.m D. Maino D. Clm ical beH lal objectives: dSsessmenttechniques for special popufalions In Maino D(ed).
ge avl • Blur.
Diagnosis and M 'm 01SpeclJI PopulatiO SI. Louis MO Mosby-Yearbook, Inc . 1995:15Hl8.
antlg ent nS. A more recent stud y no tes that
• ~Il!liman M W B. Clinical Manage;nenl of Binocular ViS : Heterophoric, AccommodaliV1), and E Movement
ick ion ye
Discrdw' P II.delphi.: Lippincott: 2008.
O
conflicts in motor responses drive
• Pang Y. Gabriel H, Frantz KA. Saeed F. Aprospective study of dilferentlesllargels for the r.ear painl of convergence visual discomfort a nd fatigue
OphllJ.]lmiC Physiol Op! 2010 May;30(3)298-303
because, if the visual system does
not a ttempt to make a motor
• Dizziness: 3-D techno logy ca n fourth D of 3-D viewi ng shou ld be: response when a vergence-accom­
exaggerate visual motion hypersen­ If you do not appreciate 3-D or you modation con£lict is present, no
sitivity (YMH) or vision-induced experience asthenopia while watch­ discomfort occurs. 1 This is an
9
moti on sickness which can cause ing 3-D content, you should imme­ interesting finding because at least
individuals to feel dizzy o r nau­ diately make an appointment with one other paper suggested the
seous during or after viewing 3-D your D octor of Optometry. H primary ca use of symptoms in a t
content. Tbe way to crea te a better 3-D least one binocular vision disorder
• Lack o f Depth: A viewer lack- viewing audience is first to di agnose (convergence insufficiency) is the
60 REVIEW OF OPTOMETRY ~) CI{) ~~ll 1",1'011

5. Pha e of Optometric Vision Th rapy associated dysfunction noted in
Phase 1 accommodation. lo
Monocular: The monocular phase of therapy often includes the following oculomotor, hand­
eye and accommodative therapy procedures: Treating 3DVS
• Hart chart saccades No stanJard, successful treat­
• Hart chart accommodative rock (WWW.youlube.com/watch?.J- tX8matodzgs) ment has yet been esta blished for
• Rotating pegboard 3DVS. However, at last year's
• Computer paddle ball (www.youtube.comlwatch?v-EenLQ3mKow J American Academy of Optometry
• Bunt ball (www,yoytube.comfwatcll?v=BTy3080wONB ) meeting, we presented a single sub­
• Plus and minus lens flippers ject design study that clearl y dem­
• Wayne saccadic fixator (www.youtube.com/walch?v-S21z6hBpFOy) onstrated how a patient with 3DVS
• Vision coach lwww.youlube.com/walch?v==kbcXr5IxXAM) can be treated successfully with
optometric vision therapy (OVT)Y
Phase 2 (See "Phases of Optometric Vision
Biocular: The biocular therapy phase is often used to break down any suppression present Therapy, ., left.)
and includes oculomotor, hand-eye, accommodative and anti-suppression therapies: The poster described a 27-year­
• Barrel card (WWW.voutube.comlwatch?v- HtzEHSle-90) old white female who began to
• Split vectogram (www.voutube.com!walCh?v=Tzieb5g0vJA) experience severe symptoms after
viewing a 3-D movie for 15 to 20
Phase 3
minutes. These symptoms includeJ
Binocular: This binocular phase of therapy often includes the following oculomotor, hand­
blurred visiun, diplopia, eyestrain,
eye (if still needed), accommodative and vergence therapy procedures:
visual tracking problems, head­
• lifeSaver cards BI (www.yaulube.comlwalch?v=Ul3KTZOdzbo) ache, nausea and vision-induced
• lifeSaver cards BO (www.YOutube.com/watch?v=:wGYX684r3xQ ) motion sickness. A comprehensive
• Brock string (WWW.youlube.com/wB!ch?y=EGICVTdNafw) examination noted reduced random
• Vectograms (www.YOutube.com/watch?v<=0IuzE6hc7NI) dot stereopsis, no positive/negative
fusional ranges (immediate diplo­
Fun with vectograms. pia), and high exophoria at near.
Also, she reported diplopia while
accessing accommodative facility.
The initial findings included a vari­
able Monocular Estimation Method
(MEM dynamic retinoscopy), pain
upon near point of convergence
testing, and reduced positive rela­
tive accOlllmodation and accommo­
dative amplitudes.
We diagnosed this p<uient with
Phase 4
convergence insufficiency, accom­
Integration/Stabilization: This phase includes combined oculomotor/hand-eye/accommoda
­ modative infacilitylinsta biLiry/
tive/vergence therapy. (This is where you might use plus or minus lens and/or prism flip
­ insufficiency, and diplopia . She
pers with Vectograms, aperture rule and other vergence and/or oculomotor activities.)
was prescribed in-office OVT and
• Brock string with flippers (www.youtube.com/watcll?v==5S fYs-EAlO) home VT. After the first six therapy
sessions, all symptoms were either
Also note that although randomized clinical trials have shown that in-office optometric improved o[ eliminated. Upon com­
therapy is most effective for binocular vision disorders, home computer therapy is helpful pleting a program of out-of-officc
for treating these disorders as well. These home therapeutic digital programs include but (eight sessions) and home-based
are not limited to Home Therapy Systems (www.homevlsiontherapy.com). PVT Perceptual optometric vision therapy, all find­
Visual Tracking and Amblyopia iNet (www.visiontherapysolutions.net). and Computer Aided ings normalized and all symptoms
Vision Therapy: Track and Read and Computer Vergences (www.cavl.net). relieved.
The patient was so pleased with
62 REVIEW OF OPTOMETRY OCTOBER 15 . 201 1

6. 4. Almont Green. hnp:/lalrnQfilgreen com. Accessed July 14. Lambooija,M. Fortuillii MF, IJ>SIllsteijn W Heyndenc:i<x
A.
thera py outcomes that several 2011. I. Visual discomlort assoctaled wlih 3D displays. Ploceed­
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in the middle of watching a 3-D Toward a comprehensive assessment olliser experience and Quality Metrics for C Qnsurrer E lectronics VPQ M-20 1 0
wilh 3~. Proceedings ollhe Fifth International Workshop Available at hno{/gIlQub lullDO 3S!.t edUiresoIYoar1JllrOOm101
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to text me about how much she Eleclronics VPQM-2010. Available at: hllll/leowb lulluo 2011.
asuedu/resplvoomivoomlO/PrOCeedlOOS YPOM2QlOi 15. Iwasaki S. KubotaT, T <Ira T loleJance rilllge of
av.' he
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ano
meOlst20 tl/6!ll611 b+1 13!hedilion.odt. Accessed July visuallatigue and visual comfort fO 3 D H lVlHDTV
r D
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0 30.
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