**No financial interests to declare.

Graham Peachey B.Optom, FCOVD, FACBO.Australia.

To champion the availability and delivery of evidence based,

gold standard, functional vision care.

March/April 2010

ASSESSMENT TRAINING

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Individuals performance compared to normative database. Developmental expectations for KPI’s at each age. (Ref. 1)

Samples :Samples :Express Eye. FonoFix.

Fixation Instability (Mon.) Saccadic Organization.

p17P36

Binocular Instability (B) CountFix.

Anti-Saccade Performance in Dyslexia

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1. Functional Vision Defect :A fault or imperfection in the ‘hardware’ of the visualA fault or imperfection in the hardware of the visual system.

2 F i l Vi i D fi i2. Functional Vision Deficit:Less than required or expected ‘software’ due to neuro-developmental delay &/or schemata breakdown.p y /

3. Visual Dysfunction:Has ‘behaviour’ indicative of aspects of Functional Vision not working properly.

Optomotor Factors : Deficits

(Developmental Voluntary Control)

Ocular-Motor Factors : Defects

(Structure & Physiology)(Developmental Voluntary Control) (Structure & Physiology)Fixation Stability Strabismus; Palsy; Nystagmus;Binocular Stability(B fi i )

Heterophorias; Fixation disparity; CI M h i(Between fixations) CI; Myasthenia; etc.

Saccadic Organisation(Measures response time, accuracy and self correction)and self correction)

Visual Inspection “Operational Organisation and Endurance” Performance Tests : Dysfunction

#21 Point; NSUCO Ocular Motility Test, DEM; Groffman Tracking;Accomm, :Ret – MEM; # cyl; +/- Flipper; Keystone FVP – VEE ; VO Star ; Cheiroscopic Tracing ; Visagraph etc

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Keystone FVP VEE ; VO Star ; Cheiroscopic Tracing ; Visagraph etc.

ENVIRONMENT BIOLOGY / PHYSICS Genetics

Social BODY Structure , eg.Optical Integrity SOptical Integrity, SystemPhysiology, Ocular Motor,Pathways & DefectPathology.

DietTrauma/Disease

PERCEPTION - OPTOMOTORCOACHCOACH

ZPD MIND Theory of Mind Developmental( Neuro Developmental ) Acquisition of

Schemata / Breakdown COGNITION DeficitCOGNITION Deficit

BEHAVIOUROperational organisation Performance

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& endurance,DYSFUNCTION

Functional Vision – A cascading interaction of three areas;Area 1; Body factors, systemic and ocular health, clarity of sight, integrity of neurology,

structures , general & ocular motor physiology, etc.structures , general & ocular motor physiology, etc.

Area 2; Visual Inspection ;A. Assessing the developmental status of;

Fixation Stability Binocular StabilityFixation Stability, Binocular Stability,Saccadic Organisation, Subitizing and Count.

B. Operational organisation and Endurance. Schemata breakdowns with Tracking, Focus & Teaming.

Area 3; Visuo-cognitive Operations; Three domains – (Ref’s. 2, 3)Sensory Motor ( aka :VIP ) , Evolving Self, Problem Solving.

Visual Spatial Mindful Awareness of eg. Object Permanencep g jVisual Analysis Body Construct Size , Shape Constancy Visual Motor Self Awareness Motor / Visual Hierarchy

Self MonitoringVisual Auditory Self Correction Impulsive / Reflective sua ud to y Se Co ect o pu s e / e ect e

(Fono Test ) Self OrganisationConservation / Logic

(Ref’s. 4, 5) 8

Fischer et.al. (Ref. 6) state ...........“... it is not the saccade control system as a whole which exhibits

developmental deficits in dyslexia. The eye muscles and the brainstem mechanisms for saccade generation are usually intact and do not show any systematic deficits.”...............

.....” It is the frontal lobe component, which regulates the synchronization of the ongoing reading process & saccade generation, that is not well established.” p 18.

Clinical Pearl (1):“These Neuro – Developmental KPI Deficits are

not detected by a traditional defect ‘Eye Exam’ .”

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Research on Optomotor & Perceptual factors is extensive Research on Optomotor & Perceptual factors is extensive.

Prof. Fischer and team have made significant contributions eg:

1. Discovered Express Saccades, 1983 (Ref.7); 1984 (Ref.8)

2. Established developmental KPI milestones .

3. Showed developmental deficits co-exist with Dyslexia, ADHD, Dyscalculia and General Learning Dysfunctions.

4. Demonstrated that developmental KPI deficits are typically treatable (87% prognosis).

5. Successful treatment of KPI deficits transfers to related educational areas.

6. Turn-Key system for clinical neuro developmental assessment: 2002. (Ref. 9)

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E E Express Eye.Uses three mini-lasers and infrared Sensors that make about 1000 readings per second. Stability of projected lights determined by body/head control. p j g y y/Two measurement protocols : * Pro-Saccades,* Anti-Saccades. Each have 200 presentations takes about 8 minutesEach have 200 presentations takes about 8 minutes .

Data Recorded : ( New Information )b l1. Fixation Stability,

2. Binocular Stability,3. Saccadic Organisation :

Response Time, Response Accuracy, Self Correction ~ % of errors, Self Correct Response Time & Accuracy.

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Fix Test : Fall back procedure when Express Eye can not be done !Can be used as a ‘screening’ Performance Test.

Not able to measure Response Times (b t gi es o erall time to• Response Times (but gives overall time to complete);

• Number of Express Saccades;• Pattern of self correction.

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Count Fix:

Challenges the visual system as to its capacity to recognize the number of items that are simultaneously presented for a short period of timetime.

(Basic Tachistoscopic Procedure for ‘Where is It” ; depends on Fixation engagement, short term memory & attention shifts to Count above 4 )memory & attention shifts to Count above 4 ).

Comp ter contains ‘de elopmental e pected’Computer contains ‘developmental expected’ data for subjects aged 7 to 55 years. Results are displayed relative to this data . ( Ref. 11, 12. )

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Assessing 5 aspects of Auditory-Spatial Integration.

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S h t M d lSchemata Model.( Ref. 12,13,14,15,16,17,18,19. )Fix Train VT: Used to treat & monitor progress with : Used to treat & monitor progress with :

Unstable Fixation ( Poor Magno to Parvo switch ) Slow Fixation Release ( over hold on Parvo )Anti Saccade deficits.

Used at Clinic and complemented with : MIT ; After Image death ray; Peg rotator;Head torch ; Yoke Prism orientation; Accommodative procedures etc.

We do not use the Fix Train for home training.

VT Rx. changes used to foster visual engagement ; Held affect (Ref.17) Vegan affect (Ref.20) A/CA relationship (Ref’s. 21, 22)

Clinical Pearl (2 ): Diagnosis drives VT curriculum plan.

Activities are - Specific; Sequential; Adaptive; Repetitive: VT ~ Can not be “business as usual”.

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Started after ‘anti-saccade’ performance is about equal to developmental expected or plateau.

Samples of activities include;Geoboard/peg boards (Battleships codes),Parquetry blocks.Parquetry blocks.Parquetry tack. Space Fixator for ‘soft looking’.Touch induced visual imagery.Matching – Domino’s, Dice, Cards,Sorting. 100 Squares. Flashcards. (Dots.)

Count Train : Used as a Clinic VT station & to assess progress.

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Commenced after the individual has organised their personal space ‘construct’ and has reached developmentalpersonal space construct and has reached developmental expected with Count Train.

Sample home activities include;Sample home activities include;Rhythm activities, Metronome, Point to bell.Listen – Visualise and Repeat. VADS.Xylophone – Intensity Frequency Side Order Gap DetectionXylophone Intensity, Frequency, Side Order, Gap Detection.Rosner Auditory.

Fono Train: Used as a Clinic VT station & to assess progressFono Train: Used as a Clinic VT station & to assess progress.

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Pre-examination data;DOB 11/8/00Year 3 2009Year 3, 2009. Middle child of 3 children. ( Family History – Neg. All high achievers.)School questionnaire : Teacher reported reading below grade level.Reason for consult – slow reading and writing, confuses word beginnings.g g, g g

Symptoms reported at initial consult (20/2/9); ( Parent.)Slow school progress, tracking difficulties, eyestrain at near, mistakes words with similar beginnings. Handwriting and spelling difficulties.

Reports provided:Reports provided:Psycho-ed. assessment requested; parent reported all was ok. Report withheld.

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1. Healthy Eyes.y y2. Functional Vision : Initial Exam. 20/2/09.A. Unaided VA R 6/6, L 6/6.B. # 4 R +0.50, L +0.50C #7 R +0 50 L +0 50 (# vertical 1 00 ou still vert)C. #7 R +0.50, L +0.50 (# vertical, -1.00 ou, still vert).D. #14 Poor JND’s, +0.75, 3-5 exo.E. #20 -3.00F. #21 +1.75G. Keystone FVP : H. Remote NPC : 14 cms., Binocular String, 8cms behind bead. Exo posture.

3. Tests conducted; 26/2/09. TVPS – Above average. Skilled. Express Eye – CND. Fail. Fix Test – Below expected – DX Fixation Instability. Fail. Wold Sentence Copy – 1st min 16 letters 2nd min 19 letters Fail Wold Sentence Copy 1 min.16 letters, 2 min.19 letters. Fail. Gardner – 2 errors. ( Slow ; not automatic. ) B/L. Count Test – poor accuracy. Fail. Vergence ranges – fails base out recovery. BO : x/12/2.

BI /18/12BI : x/18/12.

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Di i d l l l d fDiagnosis: Neuro-developmental visual inspection deficit. Fixation instability. Convergence Insufficiency Syndrome.

Vi l M t I t ti Diffi lti Visual-Motor Integration Difficulties.

Recommendations:Spectacles for VT and close workSpectacles for VT and close work.VT Prognosis : Good gains - 15 CBVT visits ; conclude - 24 visits.

Out Come:Out Come:Parents ‘self discharged’ after 15 CBVT visits.Reported now reads books by chapters , instead of by the paragraph.Optomotor and Perceptual KPI deficits successfully treated.Binocular & VMI better but still low .

‘At Risk’ for Reading to Learn related functional vision problems.

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Blue -

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Pre-examination data;DOB 18/5/1996 : Year 7, 2009. Youngest of 3 2 older sisters ( Family History Neg )Youngest of 3 – 2 older sisters. ( Family History – Neg.)No school questionnaire possible.Reason for consult – Need for new glasses ; R eye turns out & noted more often.

2nd. Opinion. Vi i diffi l i ‘ d’ i 3Vision difficulties ‘treated’ since age 3.Frequent reviews – OMD & OD. Patching .Last Exam; 10 months ago. Told ‘glasses’ only treatment required.

( Myelinated nerve fibres.)( y )

Symptoms reported at initial consult (14/1/09); Aet 12 .6 years.“R eye lazy” Glare sensitivity with bright lights.Holds book close. Can only read comfortably for 10mins.Squints to see far. Avoids close work, behind potential at school.

Sport : High performer

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Sport : High performer.

Major Test Results: Express Eye – - Below limits for age. ( To come.)p y Keystone FVP – Far : Vert. 0 ; Horiz. 11 Exo.; Flat Fusion 4 / 2 Balls ( Supp. OD.)

Large Stereo 5 / 2; Fine Stereo 9/12 ; Randot Stereo +; Col. Vis. WNL. Near: MFBF Supp. OD; Stereo 3/6; Horiz. 11 to 19 Exo ( Pointer); Flat Fusion 4 /2.

F Fi FonoFix - Below expected for age.

CountFix– Unskilled.

VO Star- VMI : R eyed.

( R Handed )

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R Exotropia – intermittent. Basic Exo. Convergence Insufficiency Syndrome. VO Star : R eye preferred.y p Learning Related Vision Problems. Mild LD ?

Recommendations;Recommendations;10 week trial of VT, then reassess to determine progress.Expect functional vision skills would be improved in up to 30

CBVT sessions but may require surgery to make binocularCBVT sessions, but may require surgery to make binocular teaming easier.

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Keystone VEE – Distance 1 VA L 6/5 1 R 6/9 OU 6/5 11. VA: L 6/5-1 ; R 6/9; OU 6/5-12. Fixation Disp. Horiz. Ortho, Vert. Ortho. C/P Stab. Easy.3. Mac. Suppress. All correct. ( R,L. & OU.)4. Convergence A, 0-5, B, 0-24, C, 0-24. Easy but slow.5. Divergence A, 0-12, B, 0-12, C, 0-12. Easy but slow.

Fusional Convergence. Fusional Divergence.

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Keystone VEE – Near.1. VA L 6-2 R 5-2 OU 6-22 BDPQ 3D +ve Upper case 22 secs2. BDPQ 3D +ve, Upper case 22 secs,

Lower case 25 secs, all correct.3. Convergence A 0-24, B 0-24, C 0-24 Easy and skilled.4 Divergence A 0 10 B 0 14 C 0 20 Easy but slow4. Divergence A 0-10, B 0-14, C 0-20 Easy but slow.5. Fixation Disp. Horiz. Ortho, Vert. Ortho, C/P Stab. Easy.

Fixation Disparity ( Near.)

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C 1 A l ‘Fi i I bili ’ d fi i dCase 1 : At least some ‘Fixation Instability’ deficit cases respond to developmental VT sequence ( # 22, 23.) where Fix Train is preceded by : a) General Movement Patterns :Orientation of body head eyesa) General Movement Patterns :Orientation of body, head , eyes.

( Anti-Gravity ) Mobility & Balance. Directionality.Space/Time exploration with Rhythm.

b) Special Movement Patterns : Where is It ; How do I manipulate Itb) Special Movement Patterns : Where is It ; How do I manipulate It.( Centering )

Clinical Pearl ( 3 )Clinical Pearl ( 3 ).The ‘Evolving Self’ is facilitated by making Mindful Awareness a

component of VT. (Vygotsky Theory & Socratic questioning.)( yg y y q g )

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Case 2 :a Significant binocular instability case – responded to sensory and motora. Significant binocular instability case responded to sensory and motor

learning strategies beyond monocular VT.

b. ‘Reading to Learn’ VT typically needs to go beyond normalisation of O & P l d fi iOptomotor & Perceptual deficits. VT now requires : d) Advanced Visual Inspection VT.

e) Vision , Language Patterns.f) Visualisation Patternsf) Visualisation Patterns.

Clinical Pearl: ( 4.)New precision in Diagnostic Work-Up: Moves the process from Symptom Directed Guessing;

To Mind; Measurement & Management. g

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1. I expect an Up-serge in Public Interest looking for ‘ A Sensory Fix for Problems in School .’

2. New Information for Clinical Optometry.

2. Educational, Mental Health, Social Justice & National Economic IIssues.

3. Paradigm Shift Required !

4. A Speciality Service beyond Primary Care .

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Optometry has solidly researched clinical procedures for:

1. Objective neuro developmental deficits diagnosis in basic Optomotor & j p g pPerceptual areas. ( Mind .)

2. Measurement of KPI’s : Fixation stability, binocular stability between fixations Pro & Anti saccade control accuracy and self correction can befixations, Pro & Anti saccade control accuracy and self correction can be made.

3. Measurement of Response Time : Temporal ‘measurements’ of response time can be analysed for an understanding of the level of motor control: Reflex , Conscious Voluntary , Semi Automatic Voluntary.

4 Treatment Efficacy : Typically ‘deficits’ improve with VT ie. Builds neural4. Treatment Efficacy : Typically deficits improve with VT ie. Builds neural networks = Changes Minds.

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1. The integration of Neuro-Developmental optomotor & perceptual KPI assessment is an initial challenge – but worth the effort.

2. The Neuro- developmental , first generation, objective assessment technology is a unique system that ‘value adds’ in specialty VT clinics.

3. Holistic Optometric VT ‘value adds’ to the Turn-Key training units.3. Holistic Optometric VT value adds to the Turn Key training units.

4. The high incidence of ‘treatable functional vision deficits’ requires more Specialty VT clinics to emerge with co-management strategies connectingPrimary care and VT providersPrimary care and VT providers.

5. Vision care politics :Research is available, applicable, defendable and promotable ;Connects ‘Mind ; Measurement ; and Management’ Neuro Science to VTConnects Mind ; Measurement ; and Management Neuro Science to VT.

Clinical Pearl: ( 5). ‘Management’ is empowered by KPI ‘Measurement.’ g p y

Thank You ! 33