To BV or not To BV: That's No Longer the Question, but the Answer

To BV or Not to BV: That is No Longer the

Q iQuestion, But Rather the Answer!

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor, Pediatrics/Binocular VisionIllinois Eye Institute

Illinois College of OptometryChicago, Il

Lyons Family Eye CareChicago, Il

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.

Executive Summary

• Binocular vision in the news

• 3D Vision Syndrome in the newsy

• High incidence of BV problems

• Evidence based medicine/research supports optometric vision therapy

Executive Summary

• Amblyopia can be treated at any age

• Learning related vision problems g poptometric intervention supported by research

• Attention and binocular vision problems related

Executive Summary

• Our patients are in pain

• Proven examination techniques• Proven examination techniques available

• Proven intervention/therapy available

Executive Summary

• The myths of OVT wrong

• Expand your patient base• Expand your patient base

• Be unique

• Offer more

BV Dx & Tx in the News!! BV Dx & Tx in the News!!

BV Dx & Tx in the News!! BV Dx & Tx in the News!!

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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%


• 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 +


• Convergence Excess: ~6%Convergence Excess: 6%

• 18 million +


• Accommodative disorders: 3-5%Accommodative disorders: 3 5%

• 15 million +


• If any other disease had this l i ld bprevalence, it would be

considered an epidemic…if not a pandemic!

Subjective Complaints of Patients with BV Disorders

• Blur• Headache• Headache

• Aesthenopia

• Diplopia

• These complaints are usually associated with near work


• Blur

• Headache• Headache• Aesthenopia

• Diplopia



• Blur

H d h• Headache

• Aesthenopia

• Diplopia



• Blur

H d h• Headache

• Aesthenopia

• Diplopia


Visual Efficiency Examination: Basic Tests

•History

i l A i•Visual Acuity

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R f ti E l ti• Refractive Evaluation (Objective/Subjective)

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• Oculomotor – Cover Test, Hirschberg,

– Kappa, Krimsky, Bruckner

– EOMs

– NPC (with red lens)

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• Heterophoria

• VergencesVergences–Sheard’s criteria

• Need twice your phoria in reserve (10 pd exophore at near needs 20 pd BO reserves)


• Accommodative Tests –Minimum amplitude =Minimum amplitude

15 - (0.25) age•So a 20 year old should have at least 10 diopters of accommodation


–NRA/PRA, Minus Lens Amplitudes


–Push Up/Pull Away A lit d MEMAmplitudes, MEM

–Facility

Basic tests

• Stereopsis

• Random Dot,,

• Stereo Fly• Less than

70 seconds of arc

Basic tests

• Worth 4 Dot

Fi ti Di it T ti• Fixation Disparity Testing– Wesson Card,

– Bernell Fixation

Disparity (Associated Phoria),

Disparometer

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

Convergence Insufficiency

• Signs:– An exodeviation at near

C b i i i• 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

Convergence Excess

• Symptoms: Diplopia, headaches, aesthenopia– almost always near related– 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

Convergence Excess

• Signs– Dynamic Retinoscopy

• May be the most significant testMay 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

Fusional Vergence Dysfunction

• Symptoms: aesthenopia, headaches, blurred vision (Binocular Vision/Visual Discomfort Dx)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

Accommodative Disorders

• Symptoms: blur, headache, aesthenopia fatigueaesthenopia, fatigue when reading, difficulty changing focus from one distance to another

Accommodative Disorders

• Signs– Accommodative Insufficiency:

• Reduced amplitude of accommodationp

• Minimum Accommodation:

15 - (0.25) (age)

– Accommodative Infacility• Failure of monocular facility testing

• Expected value: 11 cpm

Other BV Disorders

• Divergence Excess– Prevalence of ~0.5 to 4%

– Exophoria greater at distance than near

– Frequently first discovered in grade school

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Other BV Disorders

• Divergence Insufficiency– Very rare!

– Esophoria greater at distance than near

– Be careful to rule out lateral rectus palsy!

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Strabismus & Amblyopia

3-5% of the population

T i llTx appropriate at all ages

May do out of office VT

and achieve success!

Amblyopia

Pathological until proven otherwise

Amblyogenic Amblyogenic FactorsFactorsp

Infants/Toddlers

Young Children

Busy Adults

AnisometropiaAnisometropia

Bilateral Refractive ErrorBilateral Refractive Error

Strabismus (Constant)Strabismus (Constant)

Amblyopia

Legal Consultant

AmblyopiaAmblyopia

Malpractice case was not because of missing

an eye disease…But rather due to alleged inappropriate management/treatment

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 Optometrynon-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.



Scheimann M et al. Randomised clinical trial of the effectiveness of base-i i di l l b di l fin prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Ophthal2005;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.



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-effects of temporal vision processing therapy. Optometry. 2004 Oct;75(10):64050.

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.


Evidence Based MedicineSolan 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.



Cotter S et al Treatment of strabismic amblyopia withCotter 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.



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.g y p p ( )

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

Levi DMLevi DM. . Prentice award lecture 2011: removing the Prentice award lecture 2011: removing the brakes on plasticity in the amblyopic brain.brakes on plasticity in the amblyopic brain.OptomOptom Vis Sci.Vis Sci. 2012 Jun;89(6):8272012 Jun;89(6):827--38.38.

VideoVideo--game play induces plasticity in the visual system of game play induces plasticity in the visual system of adults withadults with amblyopiaamblyopia

Adult AmblyopiaAdult Amblyopia

adults with adults with amblyopiaamblyopia..Li RW, Ngo C, Nguyen J, Li RW, Ngo C, Nguyen J, LeviLevi DM.DM.PLoSPLoS Biol. 2011 Aug;9(8):e1001135. Biol. 2011 Aug;9(8):e1001135. EpubEpub 2011 Aug 30.2011 Aug 30.

Prolonged perceptual learning of positional acuity in Prolonged perceptual learning of positional acuity in adultadultamblyopiaamblyopia: perceptual template retuning dynamics.: perceptual template retuning dynamics.Li RW, Klein SA, Li RW, Klein SA, LeviLevi DM.DM.J J NeurosciNeurosci. 2008 Dec 24;28(52):14223. 2008 Dec 24;28(52):14223--9.9.


• Treatment modalities– Lenses

Prisms– Prisms

– Vision therapy• Traditional therapy

• Computer therapy

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Lenses as TreatmentBest Rx (clarity, comfort, function)

Refractive Error Amblyopia Concern

Binocularity Concerns

Interference with Learning

Rx if….

Myopia >5.00D Under correct eso/Fully

Depends on child’s

>5.00D (any age)

>3.00D @>1yrcorrect exo

o c d sage

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

Lenses as Treatment

• Best Rx (clarity, comfort, function)

• Accommodative disorders• Accommodative disorders– Can prescribe reading only Rx or an

add

• Exodeviations– Overminusing (DE)

– Not usually a first choice! Give add

Bifocals for Kids

Bifocal Seg Height

Infants/Toddlers

Pre-schoolers

Bi-sect pupil

Bifocals for Kids

Bifocal Seg Height

3-5 Years

Bottom 1/3 of Pupil

Bifocals for Kids

Bifocal Seg Height

> 5yrs

Bottom of Pupil

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.

Bifocals for Myopia Progression

PALs were effective in slowing progression in these children, with statistically significant 3-year treatment effects The results support the COMETtreatment 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.

Polycarbonate/Trivex Lenses

Prism as Treatment

• Can be used with CI, CE, DI, DE, Vertical Deviations

• Prescribe the least amount of prism needed• Prescribe the least amount of prism needed– Determine the associated phoria with a Wesson

Card or Bernell Box

• Fresnel Prism trial, then Rx

Optometric Vision Therapy as Treatment

• The approach of choice for CI, Fusional Vergence Dysfunctions, accommodative disorders and Amblyopiadisorders, 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

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Vision Therapy as Treatment

• Traditional therapy– Hand-eye, Vergence and Accommodative

proceduresprocedures

• Computer Therapy– Can attack hand-eye, vergence, accommodative

and oculomotor problems (Vision information processing anomalies?)

Vision Therapy for Amblyopia

• Prescribe Rx

• Implement occlusion therapy

• Active optometric vision therapy

• Monitor

• Change Rx/Tx as needed

Period of Sensitivityvs

Period of PlasticityPeriod of Plasticity

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.

Atropine

CONCLUSIONS: Weekend atropine id i t i VA fprovides 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.

Atropine

Pediatric Eye Disease Investigator Group. The course of moderate amblyopia treated with atropine in children: experience of theatropine in children: experience of the amblyopia treatment study.Am J Ophthalmol. 2003 Oct;136(4):630-9.

Atropine

A beneficial effect of atropine is present throughout the age range of 3 years old to g g g yyounger 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 planospectacle lens is prescribed for the sound eye to augment the treatment effect of atropine.

Occlusion TherapyAge (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 wks2 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




Amblyopia Therapy

What do we know about amblyopia?– More than decreased VA

– Visual-Spatial affects

– Accommodation

– Hand-eye

– Stereopsis

Active Vision Therapy

Hand-eye

Oculomotor

Accommodation

Have child “Do Stuff”

Interact with environment60/9760/97

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.


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!

























Traditional Therapy Procedures

• Hand-Eye Procedures– mazes

dot to dot– dot to dot

– cutting

– coloring

– filling in O’s

Traditional Therapy Procedures

• Vergence procedures– Brock String

Lifesaver card– Lifesaver card

– Anaglyph Series (BC920, others)

• Accommodative Procedures– Minus lens dips

– Flippers

– Hart Chart

Vergence Procedures

Brock String

Simple

Inexpensive

Easy

Effective

Vergence Procedures

Life Saver Cards

BO d BIBO and BI

Good fusion

Anti-suppression

Inexpensive

Effective

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Vergence Procedures

Fusion Cards

Random dot targets

BC 920, BC 50

Anaglyph series

Vergence Procedures

Aperture Rule

“Flying W”

Stereoscopes

Accommodative Procedures

Rock Card

Flippers

Anti-suppression

Accommodative Procedures

Hart Chart

the old standby

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

Computer Vision Therapy

• Patient can use at home, work, wherever they have access to computercomputer

• Trains eye movements, vergences, accommodation, and perceptual skills

Why use Computer Aided VT?

• “I’d like to do VT in my practice, but...”

• Patients who cannot afford office VT

P ti t h t k ti• Patients who cannot make a time commitment for office VT

• Patient compliance problems

• Insurance or Third Party Problems

How do you incorporate Computer Aided Vision

Therapy in your practice ?

• Diagnose the patient!!!Diagnose the patient!!!

• Assign a therapy protocol

• Computer aided VT in the office

• Schedule follow-up appointments

• Evaluate the patient’s progress/Follow-up

Computer Aided VT Resources

Neuroscience Center of Indianapolis

http://www.neuroscience.cnter.com/


Computer Orthoptics

HTS (Home Therapy System)

http://www.homevisiontherapy.com/

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Computerized Aided Vision Therapy

Gary Vogel, OD, FAAOAvailable from Bernell

800-348-2225http://www.bernell.com/

Brainware Safari

http://www.brainwareforyou.com/

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/

Conclusions

• Easy way to incorporate VT for BV disorders into your practice

• Monitor the output to check for compliance• Monitor the output to check for compliance and tricks!

• Remember that the key is in diagnosing patients and follow-up

VT Equipment

Use the tools discussed

You do not need a whole room of

VT “stuff”

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WWW Sites for BV/VT

Gemstonevision.Org

BV Organizations

COVD http://www.covd.org/

OEP http://www.oep.org/

949-250-8070

AAO BV Sectionhttp://www.aaopt.org/sections/bvppo/aaobvp.html 301-984-1441

BV Organizations

PAVE/Parents Active

for Vision Education

htt // /http://www.pave-eye.com/

Neuro-Optometric

Rehabilitation Association

http://www.noravc.com/

Patient WWW Sites

3 D Pictures

http://www.vision3d.com/optical/

i d ht l# tindex.shtml#stereogram

How Does Binocular Vision Work?

http://www.vision3d.com/stereo.html

Patient WWW Sites

• http://www.children-special-

d / i ineeds.org/vision_therapy/what_is_vision_therapy.html

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Position Statement on VTAOA, 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……..”

Practice Management

Myths

VT i T E i !VT is Too Expensive!

You Can’t Make Money Doing VT!

Which is it? Can’t have it both ways!

Practice Management

FirstComprehensive Examination

ThThenVisual EfficiencyStrab/Amblyopia

Follow-up

Practice Management

All BV Disorders are a Medical Conditioned ca Co d t o

CI, CE, DI, DE, Pursuit/Saccade Dysfunction

Practice Management

Accommodative disorders tend to be refractivete d to be e act ve

Accommodative insufficiency, excess, infacility, instability, etc

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Practice Management

Visual Discomfort

i i i iis a medical diagnosis

All Ages Can Benefit….All Ages Can Benefit….

More PatientsMore PatientsBetter Patient CareBetter Patient CareEvidenced BasedEvidenced Based

Do it!Do it!

Questions? Contact:

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor, Pediatric/Binocular Vision ServiceIllinois Eye Institute/Illinois College of Optometry

3241 S Michigan Ave Chicago Il 606103241 S. Michigan Ave. Chicago, Il. 60610312-949-7280 voice 312-949-7668 fax

Private Practice 773-935-2020

[email protected]

www.LyonsFamilyEyeCare.comwww.ico.edu

Health & Medicine

To BV or not To BV: That's No Longer the Question, but the Answer